NEW APPLICANT CALIFORNIA FIRMS ONLY Answer All Questions   
  Firm's Name: 
  Street Address: 
  Mailing Address: 
  City: 
  State: 
  Zip: 
  Telephone: 
  Fax: 
  Email: 
  Website: 
Firm Profile
  1. Date firm was established:  / /
       Business Type    Other 
  2. List all pre-existing entities, including acquisitions and mergers, and their dates of existence:
Dates (From) Dates (To) Firm Name
3. Number of personnel :
Principals (Do not include below)
Professionals (project managers, architects, engineers,scientists)
Technical (CAD operators, drafting, field, laboratory)
Non-Technical (equipment operators and other field personnel)
Administrative and other
TOTAL
4. List all professional societies and associations to which your firm and KEY PERSONNEL belong:
     
5. If your firm has field technicians, list certifications : (e.g., ACI,CHMM,CWI,NICET,OSHA : 40-hour, etc.)
     
6. If your firm has a laboratory, list accreditation's : (e.g., A2LA,AASHTO, state EPA, ISO, etc.)
     
7. Do any other entities, or individuals not employed by your firm, have any ownership interest in your firm? Yes No
8. Does your firm or any KEY PERSONNEL own any interest in any other entity? Yes No
If yes, list the owner, amount of ownership, name of entity, relationship to your firm, nature of activities and the entity's GROSS RECEIPTS during the last complete year.
9. Are professional services provided by your firm to any entity in which your firm or KEY PERSONNEL maintain a cumulative ownership interest greater than ten percent (10%)? Yes No
10. Provide your firm's GROSS RECEIPTS attributable to the following years.
(Include all receipts for projects insured by project policies within the GROSS RECEIPTS column and list separately in the Project Policy Receipts column.) GROSS RECEIPTS means the EXACT dollar amount of your firm's gross revenues, but not including interest income, rental income on real estate, or sales and service taxes.
Month/Day/Year Gross Receipts Project Policy Receipts
/ / Estimated Current Year
/ / Last Complete Year
/ / Two Years Ago
/ / Three Years Ago
*Complete Project Insurance Questionnaire
11. List all office locations with a contact name and the percentage of your firm's GROSS RECEIPTS derived from each location for the last complete year:
Location (address, city, state, zip & contact)
%
%
%
%
Total must equal 100%   %
12. Provide the percentages of your firm's GROSS RECEIPTS that were paid to subconsultants and subcontractors during the last complete year.
Subconsultants Insured for Professional Liability Not Insured for Professional Liability
Structural Engineering % %
Environmental Services* % %
Other Professional Services % %
* As described within Environmental Services in question 14 C.
Subcontractors (environmental only) Insured for Contractors Pollution Liability (CPL) NNot Insured for Contractors Pollution Liability (CPL)
Field services (drilling, sampling,testing) % %
Site remediation activities % %
Asbestos, lead or radon abatement % %
  13. Does your firm obtain the appropriate certificates of insurance? N/A
      From your consultants Yes No
      From your prime professionals Yes No
      From your subcontractors Yes No
SERVICES
14. Provide the percentage of your firm's GROSS RECEIPTS attributed to the following services during the last complete year.
  A. Design and Other Related Services (non-environmental)
1. Design Services 3. Field services
% Total of all design Services % a. Construction observation without design
% Percentage with construction observation % b. Inspection as a stand-alone service
% Percentage without construction observation % c. Boundary and construction staking
% d. Construction materials testing (including compaction testing)
2. Non-Design Services
% e. Drilling and sampling (geotechnical)
% a. Quantity or cost estimates without design % f. Laboratory analysis (including soils and construction materials, but not environmental)
% b. Plan checking without design % g. Other (describe)
% c. Building commissioning (quality assurance process as a separate service)
  B. Operation and Management Services (of these facilities)
% d. Feasibility, programming, planning, economic or seismic studies % a. Domestic water, utility, building, other facilities
% e. Architectural master planning % b. Wastewater treatment plants, landfills, chemical processing plants (describe)
% f. Forensic inspections, expert witness services, failure analysis % c. Other (describe)
  C. Environmental Services
1. Environmental engineering (detection, determination and remediation of contaminated sites) 2. Environmental sciences
% a. Preliminary site assessments (PSA-Phase I) % a. Permitting
% b. Other environmental assessments (compliance audits, environmental impact studies) % b. Industrial hygiene
% c. Investigations (drilling and sampling, Phase II) % c. Laboratory analysis (chemical and analytical)
% d. Studies (feasibility, siting, closure, hydrogeological, hydrological) % d. Environmental training and manuals for other than internal usage
% e. Asbestos and lead studies (inspection, identification, work plans) % e. Fish and wildlife or botanical studies, including wetland delineation
% f. Asbestos and lead abatement % f. Forensic inspections, expert witness services
% g. Design services (remediation, environmental facilities, pollution control systems)
3. Other Environmental Services
% h. Site remediation activities and remediation observation or management (describe)
% i. Environmental project observation/oversight (non-remediation)(describe) %
DISCIPLINES
15. Provide the percentages, based on your firm's GROSS RECEIPTS, attributable to the following disciplines provided by your firm, excluding your subconsultants.
Estimated
Current Year		 Last
Complete Year		 Estimated
Current Year		 Last
Complete Year
ARCHITECTURE ENGINEERING
% % Architecture % % Structural engineering
% % Architectural planning (including master planning) % % Civil engineering
% % Interior design and graphics % % Civil wastewater engineering (municipal, non-industrial)
% % Landscape architecture % % Land surveying
LABORATORY
% % Traffic engineering
% % Construction materials testing (non-environmental) % >% Mechanical engineering
% % Environmental (analytical) % % Acoustical engineering
% % Conformity assessment* (product testing and materials science) % % Process engineering
% % Life sciences* (clinical research - not diagnostic medical labs) % % Electrical engineering
% % Microbiology and analytical chemistry* (food, drugs, personal care products)
*Complete Laboratory Questionnaire		 % % Illumination engineering
ENVIRONMENTAL
% % Geotechnical engineering (soil mechanics for structures)
% % Environmental engineering (including mines and mining waste treatment) - See question 14C % % Geotechnical field services and construction materials testing (including drilling)
% % Environmental science - See question 14C
OTHER
% % Industrial wastewater engineering (non-municipal) % % Marine engineering (describe)
% % Geo-environmental engineering (including landfills, waste treatment and retention ponds) % % Naval architecture (describe)
% % Totals must equal 100% % % Other (describe)
PROJECTS
16. Provide the percentage of your firm's GROSS RECEIPTS attributable to the following projects during the last complete year.
HIGH RISE INDUSTRIAL
% All buildings over 15 stories (DO NOT classify these below.) % Processing, manufacturing and production systems
% Do any of these buildings include residential condominiums? % Mines, quarries, tunnels
RESIDENTIAL
% Oil refineries
% Residential condominiums % Chemical plants and pipelines
% Planned Unit Developments (PUDs) % Facilities related to nuclear activities
% Single-family residential subdivisions
RECREATIONAL FACILITIES
% Custom homes % Sports facilities, arenas, convention facilities, grandstands, theaters, amusement parks (describe your services for each)
% Apartments % Ski lifts, amusement rides (describe your services for each)
INSTITUTIONAL
INFRASTRUCTURE
% Hospitals, retirement homes, convalescent hospitals % Utilities
% Public schools, colleges and universities % Roads and highways
% Private schools, colleges and universities % Airport runways
% Churches % Transportation passenger terminals (describe your services)
% Correctional institutions % Structures for offshore or marine use, harbors, jetties, docks, piers, wharves
GENERAL BUILDING
% Bridges, trestles
% Parking garages % Dams, reservoirs, levees
% Hotels % Landfills
% Motels % Wastewater, sewage and water treatment systems
% Retail, malls, shopping centers % Waste treatment, storage or disposal facilities
% Office, warehouse, processing, manufacturing and production buildings
OTHER
% Restaurants % All other environmental projects (including remediation sites, e.g., National Priorities List, Superfund and UST)
% Other (describe)
Clients
  17. Provide the percentage of your firm's GROSS RECEIPTS attributed to the following types of clients during the last complete year.
% Owners
% Developers
% Contractors
% Design Professionals
% Other (describe) 
% Environmental consultants
% Public Sector
% Foreign
% Total
(must equal 100%)
Project Delivery Methods
  18. Provide the percentage of your firm's GROSS RECEIPTS attributable to projects delivered in the following manner during the last complete year.
% Design-Bid-Build (traditional delivery method)
% Design-Build
% Fast Track (describe)
% Turnkey (describe)
% Construction management*
*Do you perform any construction activities or hire contractors? Yes No
*During the last year, was your firm, or any subconsultant or subcontractor to you, responsible for construction means, methods, techniques, procedures, or job safety? Yes No
If yes to either question above, explain and provide details about your firm's GROSS RECEIPTS attributable to these services and a copy of the contract. If you use unmodified standard professional association forms, provide form numbers only, not copies.
Abandoned Projects
19. Does your firm wish to report (or reinstate) any permanently abandoned projects that were originally intended for construction and where design receipts were generated this year or within the last three years? (Do Not include master planning projects, feasibility studies or inspections.) Yes No
  If yes, complete the Abandoned Projects Questionnaire, if not previously submitted to us.
Business Practices
20. Do your firm's quality control procedures include:
A written quality control manual Yes No
Procedures for reviewing all client and subconsultant contracts before they are signed Yes No
Use of specification and design checklists as well as procedures for their review Yes No
Procedural or technical manuals for both in-house and field personnel Yes No
Continuing education and training programs for professional and technical personnel Yes No
21. Has your firm completed an organizational peer review through a professional association? Yes No
If yes, when and by whom?
22. Provide the percentage of your firm's GROSS RECEIPTS derived from the following during the last complete year.
% Your firm's standard contract form (attach copy)
% Your firm's letter of agreement (attach copy)
% A professional association contract form
% Your client's contract form *
% Your client's purchase order form *
% Verbal agreements **
% Other (describe)
% Total must equal 100%
* Describe what steps your firm takes to protect itself against unfavorable contract language.
** Describe what steps your firm takes to confirm agreement by all parties.
23. Does your firm enter into contracts which give ownership of your documents to clients? Yes No
If yes, do you use a written disclaimer regarding reuse of those documents? Yes No
24. Does your firm design any building, system, or component that is intended to be used for more than one location without adaptation? Yes No
If yes, describe.
25. Does your firm use a limitation of liability provision in its contracts? Yes No
If yes, complete the Limitation of Liability Report for possible premium credit.
Claims
26. In the last five years, has your firm had a claim against your practice, or against you on a product policy, as described below? Yes No
If yes, complete a Claim Questionnaire for each claim.
Claim means : (a) a demand against you for money or services, or the filing of a suit or the initiation of an arbitration proceeding naming you, seeking damages for all alleged error, omission, negligent act : or (b) an event, a circumstance, an incident, or unresolved fee dispute, of which you have knowledge that may result in a claim as described in (a).
Insurance
27. Identify your firm's current commercial
      general liability insurance company:
      Expiration Date:
      Policy Limits:
28. Provide the following information about your firm's professional liability insurance: None
  Expiration Date
(from/to)		 Insurance
Company		 Limits of
Insurance		 Deductible Premium
Current Year / $ $ $
Last Year / $ $ $
Two Years Ago / $ $ $
Three Years Ago / $ $ $
Four Years Ago / $ $ $
  Retroactive date on current policy:
Quotation Options
29. Indicate which options your firm wishes quoted for professional liability insurance:
Combined Single/Aggregate Limit Split LImits Per
Claim/Aggregate		 Deductible Per Claim
$250000
$500000
$1 Million
$2 Million
$3 Million
$4 Million
$5 Million		 $250000/500000
$500000/$1 Million
$1 Million/$2 Million
$2 Million/$4 Million
$3 Million/$5 Million		 $5000
$10000
$15000
$25000
$50000
Shared Cost of Defense  Dollar One Defense
Additional Information
30. Provide any information that will further our understanding of your firm.

CLAIMS REPRESENTATION / SIGNATURE


I specifically asked all principals and project managers in our firm if they have knowledge of any claim or potential claim against us that is not listed in our response to question 14. There are none.

If we become aware of any claim or potential claim against us, before the inception of coverage, we will immediately inform the Company, Agent or Broker. We understand that any claim or potential claim against us, before the inception of coverage, whether identified to the Company or not, will not be covered by this insurance unless specially accepted by the Company.

On behalf of our firm, I agree that this application, including all attachments and exhibits, is complete and correct to the best of my knowledge and belief. I understand that this application forms the basis of the contract of insurance, if the Company offers coverage and we accept the Company's offer. I also understand that completion of this application does not bind the Company, Agent or Broker to provide insurance.
  Name of Principal, Partner, or Officer:
  Title:
  Date of Application:  
  What is important to your firm in your
  selection of a professional liability company?		 Agent recommendation
Claims service
Company reputation
Educational programs
Policy coverage
Price
Professional society endorsement
Other:

 

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