CONTRACTOR S PROTECTIVE, PROFESSIONAL AND POLLUTION LIABILITY INSURANCE APPLICATION FORM. Limits of Liability Requested: / Deductible: /

Transcription

1 PROFESSIONAL AND POLLUTION LIABILITY INSURANCE APPLICATION FORM Coverage Desired: Protective Liability Professional Liability Pollution Liability Limits of Liability Requested: / Deductible: / / / / / 1. a) Name of Insured and all subsidiary companies to be insured under this Policy: b) Insured Address: c) Web site: d) Contact name: e) Contact phone: Fax: 2. a) Description of Contracting Operations and/or Professional Services: b) Number of Staff: Principals Licensed Architects Licensed Engineers Construction Managers Superintendents Other Technical Consultants Total Staff: PROFESSIONAL AND POLLUTION LIABILITY INSURANCE Page 1 of 7

2 c) Please provide a geographical breakdown (by percentage) of your business in the U.S.: AL HI MI NC SC AK ID MN ND SD AZ IL MS OH TN AR IN MO OK TX CA IA MT OR UT CO KS NE PA VT CT KY NV RI VA DE LA NH SC WA DC ME NJ SD WV FL MD NM TN WI GA MA NY RI WY d) Do you do any work outside the U.S.: If Yes please explain 3. a) Revenue Data Service Performed General Construction Only (No Design or CM responsibilities Construction Management At- Risk Construction Management Agency Design/Build w/ in-house Design Design/Build w/ sub-contracted Design In-House Design Only Services for Third Parties Development, Property Management, Real Estate Agent, or Leasing Agent Fees Other Technical or Professional Service Fees (please explain) Totals: Past 12 Months Construction Values Past 12 Months Professional Fees Upcoming 12 Months Construction Values Upcoming 12 Months Professional Fees b) Have there been any changes to the scope of services rendered by your Firm in the past three years? If yes please describe: PROFESSIONAL AND POLLUTION LIABILITY INSURANCE Page 2 of 7

3 4. Project Types Percentage of your Firm s Revenues attributable to the following project types (must total 100%): Project Type % Project Type % Airports Nuclear/Atomic Apartments Office Buildings Bridges Parking Structures Churches Petro/Chemical Condominiums Power Plants Convention Centers Recreational Dams Roads/Highways Environmental/Remediation Schools/Colleges Harbors/Piers/Ports Shopping Center/Retail Hospitals Stadiums Hotels/Motels Telecomm House: Custom Tunnels House: Multi-Unit Townhouse Utilities Interior Fit-Out/ Renovation Wastewater Treatment Plants Jails Water Systems Landfills Libraries Manufacturing/Industrial Mass Transit Mines 5. Contracting Procedures: a) What percentage of your work is from repeat clients? % Largest client? % b) What percentage of your work is negotiated? % Hard bid? % c) Does your firm have a financial/equity interest in any projects? If Yes, please identify and describe: d) Percentage of your firm s revenue attributable to the following client types for the last complete year: Private Developers % Commercial % General Contractors % Federal Government % Government % Local Government % Industrial % Design Firms % Other % PROFESSIONAL AND POLLUTION LIABILITY INSURANCE Page 3 of 7

4 e) List your most recent year s number of projects by size: Construction Value Number of Projects Up to - USD10,000,000 USD10,000,000 - USD25,000,000 USD25,000,000 - USD100,000,000 More than USD100,000,000 Total f) What percentage of your firms professional services or operations are performed under written contracts? % g) What percentage of your firm s contracts are: AIA % AGC % DBIA % EJCDC % Client Drafted Agreements % Firm s Standard Agreement % Purchase Orders % Master Service Agreements % h) Who reviews and negotiates client and/or subcontract agreements? i) Who has the authority to review and/or approve non-standard contract agreements? j) Are Formal Change Order Provisions utilized? k) Does Your Firm use Limitation of Liability provisions in contracts? If Yes, please include a copy of the provision l) Do you follow written in-house quality control procedures? m) Do you have an in-house program of continuing education for professional staff? n) Do any projects employ any Leadership in Environmental Engineering Design (LEED) or any Green Building technologies/materials, energy efficiency use or certification? If Yes, please explain: o) Do any projects employ a Building Information Modeling (BIM) or similar system? If Yes, explain control systems in place to safeguard security, coordination, and control of design? PROFESSIONAL AND POLLUTION LIABILITY INSURANCE Page 4 of 7

5 6. Design Services a) Are you ever responsible for subcontracting design services? b) What limit of Professional Liability insurance do you require from subcontracted design professionals? USD c) Do you obtain Certificates of Insurance from subcontracted design professionals? d) Do you provide Value Engineering, Cost Reduction and/or Constructability Review Services? 7. Insurance Information: a) Please identify your Firm s current General Liability Insurance Coverage: Company Limit Deductible Policy Period Does your current coverage have any of the following endorsements: CG2243 CG2279 CG2280 b) Does your firm currently purchase Professional Liability Insurance? If Yes, please provide coverage information for the past 3 years: Company Limit Deductible Policy Period Retroactive Date: c) Does your firm currently purchase Contractors Pollution Liability Insurance? If Yes, please provide coverage information for the past 3 years: Company Limit Deductible Policy Period Retroactive Date: PROFESSIONAL AND POLLUTION LIABILITY INSURANCE Page 5 of 7

6 8. Pollution, Mold, and Fungus Supplemental a) Do you currently purchase mold and fungus coverage? If Yes, please complete information below: Limit Deductible Retroactive Date b) Have you previously had any mold incidents/claims? If Yes please describe: c) Does your firm have formal written mold protocols for the prevention/remediation of water intrusion/mold? If Yes, please attach a copy. When were the protocols implemented? Since the protocols were implemented, have there been any problems? d) Do any projects have any known environmental problems, concerns or restraints. Environmental includes but is not limited to: projects built on Greenfield or Brownfield sites, projects with wet lands restrictions, property previously used for any industrial purpose, projects with known asbestos fibers or materials in need of abatement, encapsulation or removal, any noted underground stored tanks? If Yes, please describe: 9. Claims Information: a) Has any claim, suit, notice, or legal action been made or brought (or made earlier and still pending) against your company, its predecessors, or any past or present Principal, Partner, Officer or Director or other prospective insured party of your company? If yes, please provide the following details: - Date of Claim - Allegations - Insurance Company Reserve - If closed, total loss payment (indemnity payment plus defense costs) - Defense attorney or insurance company s evaluation of claim b) Are you aware of any other circumstances or incidents which may result in a claim being filed against your company? If Yes, please provide details. PROFESSIONAL AND POLLUTION LIABILITY INSURANCE Page 6 of 7

7 c) Has any claim ever been filed by you against a design professional? If Yes, please provide details. d) Do you know of any circumstance, project problem or delay that could reasonably be expected to result in a claim? If Yes, please provide details. The applicant has read the foregoing and understands that completion of this Application does not bind the Underwriter or the Broker to provide coverage. It is agreed, however, that this Application is complete and correct to the best of applicant s knowledge and belief and that all particulars which may have a bearing upon acceptability as a Professional Liability Insurance risk have been revealed. It is understood that this Application shall form the basis of the contract should the Underwriter approve coverage and should the applicant be satisfied with the Underwriter s quotation. Declaration I declare that the statements and particulars in this application are true and that no material facts have been misstated or suppressed after enquiry. I agree that this application, together with any other information supplied shall form the basis of any contract of insurance effected thereon. I undertake to inform the Insurers of any material alteration to those facts occurring before completion of the contract of insurance. A material fact is one which would influence the acceptance or assessment of the risk. Signed:... Title:... (to be signed by Authorized Representative of Insured) Print Name:... Date:... PROFESSIONAL AND POLLUTION LIABILITY INSURANCE Page 7 of 7