Applicant's Name

Agency Name

Address

Agent

Address

Location

Email

Web Site Address

Phone

1.

  Business is a:  Corporation   Partnership   Sole Proprietorship   Limited Liability Company (LLC)

 Individual       Other

  Date organized (MM/DD/YYYY):

2.

  Is the Applicant affiliated with any other organization through common ownership?

No Yes

  If Yes, provide details. 

3.

  During the last five years has the Applicant:

  (a)  Been involved in, or are they presently considering any merger, consolidation or acquisition?

No Yes

  (b)  Changed it's name?

No Yes

  If Yes to either of the above, provide details.

4.

  Does the Applicant or any subsidiary, parent organization or affiliated organization engage in actual construction

  or subcontract construction or installation on the Applicant's own projects?

No Yes

  If Yes, complete or Supplement for Construction Related Services (AE-31000-01)

1.

  Provide the following:

Last Year

Present Year

            Projected for

          Upcoming Year

From To

From To

From To

  Total Gross Annual Fees:

$

$

$

  Total Construction Values:

$

$

$

  Total Gross Annual Payroll:

$

$

$

  Total Number of Staff:

  Number of Design Professionals:

2.

  Provide the following for each of the Applicant's key professionals:

  Name and Title

University/Year/Major

States in Which

Licensed/Registered

No. of Years

With Applicant

3.

  What professional associations do the Applicant and/or it's staff members belong to?

1.

  Provide the approximate percentage of the professional disciplines in which the Applicant is engaged.

Architecture

Engineering (cont'd.)

Construction Management*

 %

Building

 %

Environmental

 %

Design-Build*

 %

Interiors

 %

Fire Protection

 %

Fabrication

 %

Landscape

 %

Forensic

 %

Hydrogeology

 %

Naval

 %

HVAC

 %

Interior Design

 %

Engineering

Mechanical

 %

Land Surveying

 %

Acoustical

 %

Process

 %

Manufacturing

 %

Chemical

 %

Soils

 %

Materials Testing

 %

Civil

 %

Structural

 %

Other

 %

Electrical

 %

Other

 %

TOTAL

100%

*

If the Applicant provides Construction Management and/or uses the Design-Build project delivery method complete our

Supplement for Construction Related Services (AE-31000-01).

2.

  Does the Applicant subcontract work for any of the above professions?

No Yes

   (a)

What percentage of work for the above professional disciplines is subcontracted to others?    %

   (b)

Which professional disciplines are subcontracted?

   (c)

Are Certificates of Insurance for Professional Liability Insurance and General Liability Insurance obtained from

all subcontractors?

No Yes

3.

  Provide the approximate percentage of specialty services performed by the Applicant.

  Alterations

 %

Foundation Design

 %

Permitting

 %

  Building Design

 %

Geotechnical Services

 %

Product Design

 %

  Construction Staking

 %

Machinery Design

 %

Subdivision Layout

 %

  Cost Estimating

 %

Mapping

 %

Testing

 %

  Expert Witness

 %

Master Planning

 %

Other

 %

4.

  Provide the approximate percentage of the scope of services performed by the Applicant.

  Design With Construction Observation/Administration

 %

Feasibility Studies/Reports

 %

  Design Without Construction Observation/Administration

 %

Inspection/Certification

 %

  Construction Observation/Administration Without Design

 %

Consulting Not Resulting in Construction

 %

TOTAL

100%

1.

  Provide the approximate percentage of work performed during the last three years for each of the following project sizes

  based on the project's total construction value:

  <$1,000,000

 %

>$25,000,000 - $100,000,000

 %

  $1,000,000 - $25,000,000

 %

>$100,000,000

 %

2.

  Based on the total construction values, provide the approximate percentage of work during the last three years for each of

  the following based on the contractual timeframe for completion of projects:

  < 1 year   %

1 year to 3 years   %

> 3 years   %

3.

  (a) Based on total construction values, provide the percentage of work in each of the three largest states:

State

 %

State

 %

State

 %

 (b)

Does the Applicant work on any projects outside of the United States?

No Yes

 If Yes, provide the percentage of gross fees and the name, fees, construction value and location of each project.

 %

4.

  Does the Applicant specialize in specific types of projects?

No Yes

  If Yes, provide details.

5.

  Provide the approximate percentage of general project types during the last year for each of the following:

  Commercial/Retail

 %

Institutional

 %

Recreational

 %

  Industrial/Manufacturing

 %

Public Infrastructure

 %

Residential

 %

6.

  Provide the approximate percentage of any of the following project types:

  Bridges/Dams:

Condominiums:

Amusement Rides

 %

< 100 feet

 %

< 10 units

 %

Bleachers/Grandstands

 %

100 - 500 feet

 %

10 - 100 units

 %

Cellular Communication Towers

 %

> 500 feet

 %

> 100 units

 %

Chemical/Petrochemical

 %

  Buildings:

 %

Custom Homes:

 %

Mines/Tunnels

 %

< 10 stories

 %

< $1,000,000

 %

Offshore/Marine Structures

 %

10 - 50 stories

 %

$1,000,000 - $5,000,000

 %

Parking Structures

 %

> 50 stories

 %

> $5,000,000

 %

Schools

 %

7.

  Provide the approximate percentage of clients in each of the following:

  Commercial/Industrial

 %

Development Company

 %

  Construction/Contracting Company

 %

Governmental/Public Entity

 %

  Design Professional

 %

Residential

 %

8.

 (a)

  Provide the following information for each of the five largest projects COMPLETED in the last three years:

  Project Name

Location

Construction

Value

Date

Design

Began

Date

Construction

Completed

 (b)

  Provide the following information for reach of the three largest CURRENT projects:

  Project Name

Location

Construction

Value

Date

Design

Began

Date

Construction

Completed

1.

  Does any one client represent more than 50% of the Applicant's business during the last two years?

No Yes

  If Yes, provide details.

2.

  Has the Applicant ever entered into or do they anticipate entering into any joint venture contracts?

No Yes

  Note the basic policy form excludes coverage for joint ventures.  If coverage is requested complete our Joint Venture

  Supplement (SM1859).

3.

  Has the Applicant ever provided or does the Applicant expect to provide any professional services on any project

  in which the Applicant or any employee of the Applicant had, has, or will have any ownership interest?

No Yes

  If Yes, complete our Equity Interest Supplement (SM1861-02).

4.

  Does the Applicant:

 (a)

  Employ a full time office administrator or business manager?

No Yes

 (b)

  Use association approved standard contracts for at least 75% of its work?

No Yes

 (c)

  Have all contracts for each new project reviewed by legal counsel?

No Yes

 (d)

  Obtain subrogation waivers?

No Yes

 (f)

  Have at least 75% of its projects in the last three years:

  (i)

  With repeat clients?

No Yes

  (ii)

  With repeat consultants and contractors?

No Yes

 (g)

  Avoid guaranteeing the success of any project?

No Yes

 (h)

  Pre-qualify the financial viability of all clients, consultants and subcontractors?

No Yes

 (i)

  Have written:

  (i)

  Risk management procedures in place?

No Yes

  (ii)

  In-house quality control procedures in place?

No Yes

  (iii)

  Change order procedures?

No Yes

  (iv)

  Screening/pre-qualification procedures in place for clients, consultants, and contractors?

No Yes

1.

 (a)

  Limits of Liability - Indicate from the following options:

  $250,000/$250,000

  $500,000/$1,000,000

  $1,000,000/$2,000,000

  $3,000,000/$3,000,000

  $500,000/$500,000

  $1,000,000/$1,000,000

  $2,000,000/$2,000,000

  $5,000,000/$5,000,000

 (b)

  Deductible - Indicate from the following options:

  $2,500   $5,000   $10,000   $25,000   $50,000   other

 THE COMPANY DOES NOT GUARANTEE TO OFFER ANY OF THE ABOVE LIMITS AND/OR DEDUCTIBLES.

2.

  List current and prior Architects and Engineers Professional Liability Insurance for each of the last five years:

  If none, check here

   Insurance

   Company

Limits of

Liability

Deductible

Premium

Inception/

Expiration Dates

(MM/DD/YYYY)

Retroactive/

Prior Acts Date

3.

  Provide details of the Applicant's current General Liability Insurance and Umbrella Insurance:

  If none, check here

Insurance

Company

Limits of

Liability

Inception/

Expiration Dates

(MM/DD/YYYY)

  General Liability Insurance

  Umbrella Insurance

4.

  Has any insurer declined, canceled, or nonrenewed an Architects and Engineers Professional Liability

  Insurance or any similar insurance on behalf of any person(s) or entity(ies) proposed for the insurance?

No Yes

  If Yes, provide details.

5.

  Has the Applicant or any of its employees ever been the subject of disciplinary action by any authority as a

  result of their professional activities?

No Yes

  If Yes, provide details.

6.

  Have any of the Applicant's projects during the last five years:

  (a)

 Been abandoned or stopped before the completion of either design, construction/installation?

No Yes

  (b)

 Been foreclosed, or has any client, contractor or consultant gone into bankruptcy or receivership?

No Yes

  (c)

 Been involved in any litigation or arbitration proceedings?

No Yes

  (d)

 Been subject to any unresolved compensation dispute between the Applicant and any party?

No Yes

  (e)

 Had any party to a contract threaten to make a claim or demand based on actual or alleged cost

 overruns, excessive costs, delays, or any failure to meet the contract's price or time frame?

No Yes

  (f)

 Had a death or permanent disability occur during construction or installation?

No Yes

  (g)

 Have a General Liability Insurance claim reserved for or that was paid for at least $500,000?

No Yes

  (h)

 Resulted in the Applicant filing a claim or suit against any client?

No Yes

  (i)

 Been damaged in any way, or delayed in completion, due to a storm, hurricane, or any other kind of

 weather related event?

No Yes

  (j)

 Been damaged in any way, or delayed in completion, due to an earthquake, earth subsidence, building

 or wall collapse, or any other kind of geologic or seismic event?

No Yes

 If Yes to any of the above, provide details including the current status of the project and contract.

7.

  Has (have) any Professional Liability claim(s) been made against the Applicant or any person or entity?

No Yes

  If Yes, provide details in Part VII. of the application and attach currently valued loss runs from the current

  insurer and any prior insurers.

8.

  Is (are) any person(s) or entity(ies) proposed for this insurance aware of any fact, circumstance or situation

  that might provide grounds for any claim under the proposed insurance?

No Yes

  If Yes, provide details in Part VII. of the application.

If Yes to Question 7. or 8. in Part VI., provide details below for each claim, fact, circumstance or situation.  If more space is needed,

attach additional pages.

1.

  Date Claim Made:

Date of Alleged Error: 

  Current Status/Date settled:

Claim, Suit or Incident:

  Name and Location of Project:

  Claimant(s)/Plaintiff(s):

  Additional Defendant(s) (if any):

  Nature of Claim and Allegations:

  Date Reported to Insurance Company and Name of Insurance Company:

  Amount Reserved (Loss/Expense):

$/$

Amount Paid (Loss/Expense):

$/$

2.

  Date Claim Made:

Date of Alleged Error: 

  Current Status/Date settled:

Claim, Suit or Incident:

  Name and Location of Project:

  Claimant(s)/Plaintiff(s):

  Additional Defendant(s) (if any):

  Nature of Claim and Allegations:

  Date Reported to Insurance Company and Name of Insurance Company:

  Amount Reserved (Loss/Expense):

$/$

Amount Paid (Loss/Expense):

$/$

3.

  Date Claim Made:

Date of Alleged Error: 

  Current Status/Date settled:

Claim, Suit or Incident:

  Name and Location of Project:

  Claimant(s)/Plaintiff(s):

  Additional Defendant(s) (if any):

  Nature of Claim and Allegations:

  Date Reported to Insurance Company and Name of Insurance Company:

  Amount Reserved (Loss/Expense):

$/$

Amount Paid (Loss/Expense):

$/$

NOTICE TO THE APPLICANT - PLEASE READ CAREFULLY

NO FACT, CIRCUMSTANCE OR SITUATION INDICATING THE PROBABILITY OF A CLAIM OR ACTION FOR WHICH COVERAGE MAY BE AFFORDED BY THE PROPOSED INSURANCE IS NOW KNOWN BY ANY PERSON(S) OR ENTITY(IES) PROPOSED FOR THIS INSURANCE OTHER THAN THAT WHICH IS DISCLOSED IN THIS APPLICATION.  IT IS AGREED BY ALL CONCERNED THAT IF THERE IS KNOWLEDGE OF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION, ANY CLAIM SUBSEQUENTLY EMANATING THEREFROM SHALL BE EXCLUDED FROM COVERAGE UNDER THE PROPOSED INSURANCE.

FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED AUTHORIZED AGENT OF THE PERSON(S) AND ENTITY(IES) PROPOSED FOR THIS INSURANCE DECLARES THAT TO THE BEST OF HIS/HER KNOWLEDGE AND BELIEF, AFTER REASONABLE INQUIRY, THE STATEMENTS IN THIS APPLICATION AND IN ANY ATTACHMENTS, ARE TRUE AND COMPLETE.  SHAND MORAHAN & COMPANY, INC. OR THE COMPANY IS AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION.  SIGNING THIS APPLICATION DOES NOT BIND THE COMPANY TO PROVIDE OR THE APPLICANT TO PURCHASE THE INSURANCE.

THIS APPLICATION, INFORMATION SUBMITTED WITH THIS APPLICATION AND ALL PREVIOUS APPLICATIONS AND MATERIAL CHANGES THERETO OF WHICH SHAND MORAHAN & COMPANY, INC. RECEIVES NOTICE IS ON FILE WITH SHAND MORAHAN & COMPANY, INC. AND IS CONSIDERED PHYSICALLY ATTACHED TO AND PART OF THE POLICY IF ISSUED.  SHAND MORAHAN & COMPANY, INC. AND THE COMPANY WILL HAVE RELIED UPON THIS APPLICATION AND ALL SUCH ATTACHEMENTS IN ISSUING THE POLICY.

IF THE INFORMATION IN THIS APPLICATION AND ANY ATTACHMENT MATERIALLY CHANGES BETWEEN THE DATE THIS APPLICATION IS SIGNED AND THE EFFECTIVE DATE OF THE POLICY, THE APPLICANT WILL PROMPTLY NOTIFY SHAND MORAHAN & COMPANY, INC. WHO MAY MODIFY OR WITHDRAW ANY OUTSTANDING QUOTATION OR AGREEMENT TO BIND COVERAGE.

THE UNDERSIGNED DECLARES THAT THE PERSON(S) AND ENTITY(IES) PROPOSED FOR THIS INSURANCE UNDERSTAND THAT:

(I)

THE POLICY FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY TO "CLAIMS" FIRST MADE DURING THE "POLICY

PERIOD";

(II)

UNLESS AMENDED BY ENDORSEMENT, THE LIMITS OF LIABILITY CONTAINED IN THE POLICY SHALL BE REDUCED, AND

MAY BE COMPLETELY EXHAUSTED BY "CLAIM EXPENSES" AND, IN SUCH EVENT, THE COMPANY WILL NOT BE LIABLE

FOR "CLAIM EXPENSES" OR THE AMOUNT OF ANY JUDGEMENT OR SETTLEMENT TO THE EXTENT THAT SUCH COSTS

EXCEED THE LIMITS OF LIABILITY IN THE POLICY; AND

(III)

UNLESS AMENDED BY ENDORSEMENT, "CLAIM EXPENSES" SHALL BE APPLIED AGAINST THE "DEDUCTIBLE".

Note: This application is signed by undersigned authorized agent of the Applicant(s) on behalf of the Applicant(s) and its, owners, partners, directors, officers and employees

Must be signed by the owner, principal, partner, executive officer or equivalent (within 60 days of the proposed effective date).

______________________________________________

______________________________________________

Name of Applicant

Title

______________________________________________

______________________________________________

Signature of Applicant

Date

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.

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 insurance act, which is a crime and subjects the person to criminal and civil penalties.

2.  Hit this Submit button.