Hiscox Insurance Company Inc.

Transcription

1 If coverage is issued, it will be on a Claims made basis. Notice: Unless the Claim Expenses outside the limit option is required to be included by the relevant state regulation or is selected by the Applicant, this insurance coverage provides that the Limit of Liability available to pay judgements or settlements shall be reduced by amounts incurred for Claim Expenses. Further note that amounts incurred for Claim Expenses shall be applied against the Retention amount. 1. Name of Applicant: Address: Website: 2. Date established: 3. In the past five years, has the Applicant ever changed names or been party to any acquisition, consolidation, merger, or dissolution? Yes No If Yes, please describe: 4. Please describe the percentages of the following services the Applicant provides or intends to provide: Last Fiscal Year Current Year Number of Licensed Staff Aerospace Engineering Architecture Chemical Engineering Civil Engineering Construction Management (Agency) Construction Management (At Risk) Electrical Engineering Environmental Engineering General Contracting HVAC Engineering Interior Designing Land Surveying Landscape Architecture Machine, Equipment, and/or Manufacturing Marine Engineering Mechanical Engineering Nuclear Engineering Process Engineering Page 1 of 8

2 Soil Engineering Structural Engineering Other (please specify below) 5a. Does the Applicant employ a licensed architect or engineer? Yes No 5b. Please list the state(s) in which the Applicant will be performing these services and the percentage of work in that state: State Percentage State Percentage 6. Please provide the gross billings for services listed below that were performed by the Applicant: Last 12 Months Projected 12 Months Gross Revenues Construction Values Gross Revenues Construction Values Design Design/Build Actual Construction/ Fabrication/Erection Construction Management Total 7. Please provide the approximate percentages of billings derived from the following services: a. Feasibility studies, reports, and surveys not resulting in design b. Design without supervisory services c. Design and observation d. Construction/project management e. Construction observation without design f. Inspection of existing structures g. Inspections of homes/commercial properties for prospective buyers/lenders h. Manufacture, sale, or distribution of any product or service i. Development, sale, or leasing of any computer software or hardware j. Other- please specify: 8. Based upon billings, please provide the approximate percentages of the projects below that the Applicant is engaged in: Airports Amusement rides Landfills Libraries Schools/Colleges Sewage Systems Page 2 of 8

3 Apartments Arenas/Stadiums Bridges Condos/Townhouses Residential Commercial Convention Centers Dams Harbors/Piers Hospitals/Healthcare Hotels/Motels Industrial Waste Treatment Jails Other-please specify: Manufacturing/ Industrial Mass Transit Mines Municipal Buildings Nuclear/Atomic Office Buildings Parking Structures Petro/Chemical Pools/Playgrounds Pre-engineered Structures Private Dwellings Recreation Roads/Highways Sewage Plants Retail Structures Superfund/Pollution Telecommunications Theaters Tract Homes Tunnels Underground Storage Tanks Utilities Warehouses Wastewater Treatment Plants Water Systems 9. Is the Applicant firm involved in any business other than those described? Yes No 10. Does the Applicant or any related entity have any ownership in any other company? Yes No If Yes, please describe/attach an explanation (including ownership): 11. Does the Applicant provide any services on any project or for any entity in which the Applicant or any related entity has any ownership? Yes No If Yes, please describe/attach an explanation (including ownership): 12. Please provide the following information about the Applicant s key employees: Page 3 of 8

4 Name in full of ALL partners/ principals/key employees Professional qualifications Date qualified How long in practice? How long as partner/ principal? 13. To what professional association(s) does the Applicant belong? 14. Please include a list of the Applicant s five (5) largest jobs or projects during the past three (3) years and provide the requested details: Project/Client name Nature of the services performed for the client Revenue obtained 15. Does the Applicant follow in-house quality control procedures? Yes No Does the Applicant obtain continuing education for professional employees? Yes No How many professional employees of the Applicant have attended at least six hours of continuing education over the past 12 months? Does the Applicant use written contracts on every project? Yes No If No, please provide the percentage of projects where oral agreements were used: Please specify the approximate percentage of professional services rendered under AIA or EJCDC standard contracts: If non-standard contract, modified AIA/EJCDC contracts or letter agreements are used, are they reviewed by the Applicant s legal counsel or liability implications prior to signing? Does the Applicant seek a limitation of liability clause in contracts with clients? Yes No If Yes, what percentage of contracts contain this clause? Does the Applicant negotiate into its contracts a provision for alternative dispute resolution such as mediation? Yes No If Yes, what percentage of contracts contain this clause? 16. Does the Applicant subcontract any professional services? Yes No Yes No Page 4 of 8

5 17. Has any similar insurance ever been non-renewed or cancelled? Yes No 18. Is similar insurance currently in place? Yes No If Yes, please provide professional insurance information for the last five years: Insurance Company Effective (From To) Limits Retention Premium Retroactive Date on Policy? 19. Please provide the Applicant s current general liability coverage: Insurance Company Effective (From To) Type of Cover BI Limits Have any of the individuals listed in question 12 ever been the subject of disciplinary action by authorities as a result of their professional activities? Yes No PD 21. Does the person to be insured have knowledge or information of any act, error, or omission which might reasonably be expected to give rise to a claim against him/her? Yes No 22. After inquiry, have any claims been made against any proposed Insured(s) Yes No Page 5 of 8

6 during the past ten (10) years? If Yes, please provide full loss runs and/or a Supplemental Claims Information Form for each claim. 23. Limit of Liability desired: 500,000 1,000,000 2,000,000 Other 24. Retention desired: 5,000 10,000 25,000 Other NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE INSURANCE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. Page 6 of 8

7 PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365: , ). NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS MATERIALLY FALSE INFORMATION IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. Signature of person authorized to execute on behalf of the Applicant Date Page 7 of 8

8 The Applicant hereby acknowledges that he/she/it is aware that, unless the claim expenses outside the limit is required to be included by the relevant state regulation or is selected by the applicant, the limit of liability available to pay judgments or settlements shall be reduced, and may be completely exhausted, by claim expenses and, in such event, the company shall not be liable for claim expenses or for the amount of any judgment or settlement to the extent that such exceeds the limit of liability. The Applicant hereby further acknowledges that he/she/it is aware that claim expenses that are incurred shall be applied against the retention amount. It is understood and agreed that with respect to questions 20, 21, and 22, that if such knowledge or information exists any claim or action arising there from is excluded from this proposed coverage. I HEREBY DECLARE that, after inquiry, the above statements and particulars are true and I have not suppressed or misstated any material fact and that I agree that this application shall be the basis of the contract with the Company Signature of person authorized to execute on behalf of the Applicant Date This Form duly completed, together with any supplementary information, must be signed in ink or by electronic signature by the person indicated above. Signing of this form does not bind the Applicant or the Company to complete the insurance. A copy of this should be retained for your records. Signature of Producer Date Address of Producer Producer s License Number Page 8 of 8