Application - Architects, Engineers & Environmental Services Professional Liability

ARCHITECTS, ENGINEERS & ENVIRONMENTAL SERVICES PROFESSIONAL LIABILITY APPLICATION FOR INSURANCE

A.  Please answer all questions.
B.  If there is no answer, write “none” or “not applicable” in the space provided. Where space provided is insufficient to fully answer, please use a separate sheet(s).
C.  Application must be signed and dated by an authorized person.
D.  Please remember to attach the following items:
a)  Curriculum Vitae of principals, partners, executive officers, and key personnel, and professional qualifications.
b)  Brochures and/or promotional literature about the Applicant, its operations and services.
c)  Recent annual and quarterly financial statements.

E.  Please attach a copy of your Quality Control / Loss Prevention Manual or Procedures

F. Please type or print.

NOTE:

If issued, the policy will be on a CLAIMS MADE basis, and will be issued in reliance of the completeness and accuracy of the disclosures and statements in this application. The limit of liability and any deductible will apply to any claims expenses payable under the policy.

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THIS IS AN APPLICATION FOR A "CLAIMS MADE" POLICY

(WORDS AND EXPRESSIONS, OTHER THAN IN THE HEADINGS, PRINTED IN BOLD ARE DEFINED IN THE POLICY FORM.)
1. APPLICANT INFORMATION

Name of Applicant:

Address of principal office of the Applicant:

Established:

Province of Incorporation:

Type of Company: Corporation Partnership Individual Other

Key Contact and/or Risk manager:

Telephone: Website:

BRANCH OFFICE(S):

(1) Address:

Telephone No.:

(2) Address:

Telephone:

SUBSIDIARIES:

Please list all subsidiary companies for whom coverage is required under the policy, if issued.

(1) Name :

Address:

Telephone Website:

(2) Name :

Address:

Telephone: Website:

2. COMPANY INFORMATION

a) Please attach a copy of the Applicant's latest annual report, including audited financial statements with all notes and schedules, and any other relevant financial materials.

If no annual report is available, please provide a general description of the business of the Applicant:

b) During the past ten years has the name of the Applicant been changed or has any other business been purchased or any merger or consolidation taken place?

Yes No

If yes, please provide full details.

c) Is the Applicant controlled, owned or associated with any other firm, corporation or company?

Yes No If yes, please provide full details.

d) Does the Applicant or any Principal, Partner, Director, Officer, or immediate family member of any such person have an ownership interest in any project where professional services are being rendered by your firm?

Yes No

If yes, does the application seek coverage for these projects? Yes No

e) To what Professional Association(s) does the Applicant belong?

f) Is the Applicant involved with other entities in joint ventures?

Yes No If yes, please provide full details.

g) For all company(ies) stated in Question 1, please provide:

i) A list of all partners and/or directors detailing their educational qualifications, date and place acquired and date of commencement of employment with the Applicant.

ii) The number of professional personnel excluding partners and/or directors.

Full Time Part Time

iii) The number of all other personnel. Full Time Part Time

h) List (in percentage) Province(s) in which Applicant performs professional services:

Alberta / % / Nova Scotia / % / Quebec / %
British Columbia / % / Northwest Territories / % / Saskatchewan / %
Manitoba / % / Nunavut / % / Yukon / %
New Brunswick / % / Ontario / % / Other / %
Newfoundland & Labrador / % / Prince Edward Island / %

i) Does the Applicant and all staff members follow written in-house quality control procedures?

Yes No

j) Does the Applicant use computer assisted drafting programs?

Yes No

If yes, what % of design is completed using these programs? %

k) Does the Applicant have continuing education programs for professional employees?

Yes No

l) Does the Applicant use written contracts on every project?

Yes No

If no, please provide % of contracts not written %

m) Does the Applicant seek limitation of liability (LoL) clauses in contracts with clients?

Yes No

If yes, what % contain LoL clauses? %

n) Does the Applicant seek a provision for dispute resolution such as mediation in their contracts?

Yes No

If yes, what % contain such a provision? %

3. PROFESSIONAL SERVICES

a) For all company(ies) stated in Question 1, please provide:

CANADA U.S.A. OVERSEAS

Total gross fees billed last policy year (A through C) / $ / $ / $
A. Projects Insured under separate project policies* / $ / $ / $
B. Direct Reimbursables / $ / $ / $
C. All other Billings / $ / $ / $
•Construction values last policy year / $ / $ / $
•Total fees anticipated this policy year / $ / $ / $
•Anticipated construction values this policy year / $ / $ / $

b) Please provide full details of any overseas or United States work in progress or anticipated.

c) Please state the total fees anticipated during this policy year from design/construction work $

d) Indicate the approximate percentages of design/construct work performed under the following categories:

• Complete supervision during construction %

• Design services only and no construction supervision at all %

• Partial supervision of construction %

• Supervision as requested %

e) Please state those professional services performed by or expected to be performed by the Applicant Firm indicating the approximate percentage of total fees derived from each category:

Architects / % / Electrical Engineers / % / Naval Marine / %
Construction Management / % / Building Designers / % / HVAC / %
Process Engineers / % / Geotechnical/Soil Engineers / % / Civil Engineers / %
Land Surveyors / % / Structural Engineers / % / Environmental / %
Design/Construct / % / Mechanical Engineers / % / Other (describe below) / %
Interior Design / % / Testing Lab / %
Landscape Architecture / % / Other: / %

f) Please indicate the approximate percentage of work anticipated this policy year under each category:

BUILDINGS

Residential / % / Commercial / %
High-Rise Offices, Garages / % / Institutional, Schools, Hospitals, Terminals / %
High-Rise Apartments / % / Recreational, Arenas, Exhibition Halls, Exhibitions / %
Industrial, Manufacturing and Assembly Plants / % / Heavy Industrial, Ore Crushing, Cement / %
Process Industrial, Pulp and Paper, Chemical, Food and Beverage, Refineries / % / Bulk Storage Facilities, Soils, Oil and Gas Tanks / %

TRANSPORTATION

Rapid Transit Systems / % / Subways / %
Elevated Rail Transportation / % / Transmission Lines / %
Gas Pipe Lines / % / Roads and Highways, Runways, Railroads, and Switchyards / %
Materials Handing (Excluding Marine Loading, Unloading and Storage) / % / Other Pipe Lines / %

BRIDGES

Bridges and Overpasses Not Over Water / % / Bridges and Overpasses Over Water / %
Suspension Bridges / % / Lift Bridges and Swing Bridges / %

TUNNELS

Pedestrian Tunnels / % / Vehicular Tunnels / %
Vehicular Tunnels / % / Other (Specify): / %

DAMS

Temporary Dams and Coffer Dams / % / Rock Fill Dams / %
Earth Fill Dams / % / Concrete Dams / %
Other (Specify): / % / Other (Specify): / %

MARINE WORKS

Marine Storage, Cranes, Loading and Unloading Facilities (Excluding Bulk Storage Facilities) / % / Breakwaters / %
Dredging & Land Reclamation / % / Canals & Locks / %
Wet Docks, Dry Docks, Slips and Marine Railways / % / Piers, Wharves & Berths / %

WATER AND WASTE WATER SYSTEMS

Flood Control Systems / % / Power Systems / %
Mining and Oil / % / Industrial Engineering / %
Water Purification Plants And Waste Water Treatment Plants / % / Communications / %
Irrigation Systems, Water Supply Systems Waste Water Collection Systems (Including Surface Runoff) / % / Piers, Wharves & Berths / %

g) Please append a separate sheet detailing the Applicant Firms' ten largest jobs during the past five years.

Detail: i) project name

ii) type of structure

iii) services performed

iv) construction values

h) What percentage of the Applicant Firms' practice involves subletting of work to others? %

What type of work sublet?

i) Is evidence of Insurance from consultants required?

Yes No

j) Does the Applicant Firm or any subsidiary, parent or otherwise related entity engage in:

1. Actual construction, manufacturing or fabrication? Yes No

2. Development, sale or lease of computer software to 3rd parties? Yes No

3. Real Estate Development? Yes No

4. Manufacture, sale, lease, or distribution of any product? Yes No

If yes, please supply full details.

k) Does any one contract or client represent more than 50% of the Applicant Firms' annual work?

Yes No

If yes, please supply full details.

l) Is the Applicant Firm currently insured under a Comprehensive General Liability and/or Umbrella Policy?

Yes No

4. CLAIMS HISTORY AND COVERAGE

a) Has any claim and/or suit been made against the Applicant, or any past or present director, partner, officer, or employee?

Yes No

Is any applicant or any of its predecessors in business, any director, partner, officer or employee thereof aware of or in possession of any knowledge of an act, error, omission or breach of duty committed in the rendering of professional services?

Yes No

Has any individual listed at Question 1 ever been the subject of disciplinary proceedings as a result of their professional services?

Yes No

QUESTIONS 4a) REQUIRES RESPONSES REGARDING ANY CLAIM, SUIT OR INCIDENT ANY APPLICANT IS AWARE OF OR HAS KNOWLEDGE OF, REGARDLESS OF WHETHER OR NOT THERE WAS ANY VALID AND/OR COLLECTIBLE INSURANCE APPLICABLE TO SUCH CLAIM, SUIT OR INCIDENT.

Further, if the response to any part of Question 4a) is yes, please provide:

* Name of Claimant/Potential Claimant

* Date the Act, Error or Omission was committed or alleged to have been committed

* Date of Claim

* Nature of Claim

* Quantum

* Any legal opinion obtained as to liability

* Any legal, adjusting or indemnity payments to date

* Any legal, adjusting or indemnity reserves established

b) Please detail Professional Liability Insurance purchased by any Applicant for the past five years detailing the present insurance coverage first:

Company / Policy Number / Policy Period / Policy Limit / Deductible / Premium
1.  / $ / $ / $
2.  / $ / $ / $
3.  / $ / $ / $
4.  / $ / $ / $
5.  / $ / $ / $

c) Please state date on which uninterrupted Professional Liability Insurance began.

d) (i) INSURANCE REQUIRED:

Limit of Liability $ Each Claim and Annual Aggregate

Alternatively $ Each Claim and Annual Aggregate

Alternatively $ Each Claim and Annual Aggregate

(ii) Deductible $ Each Claim

Alternatively $ Each Claim

Alternatively $ Each Claim

e) To any Applicant's knowledge, has any Insurer declined to provide or cancelled insurance coverage for any Applicant, its predecessor or any past or present director, partner, officer or employee?

Yes No

If yes, please provide reason(s) given by such Insurer:

5. ACKNOWLEDGEMENT

The undersigned authorized officer on behalf of the Applicant:

·  Declares that the statements and disclosures in this application are complete and accurate;

·  Declares that there are no known facts or material to the risk to be insured that have not been disclosed in this application;

·  Undertakes to provide the Company immediate notice of any material changes discovered between the date of this application and the effective date of the policy;

·  Acknowledges that the Company, if it issues, the policy will be doing so in reliance of the completeness and accuracy of the statements and disclosures in this application;

·  Acknowledges that if issued, this application will form part of the policy.

·  Acknowledges that any personal information provided in connection with the coverage applied for, including but not limited to the information contained in this application, has been collected in accordance with all applicable privacy legislation. The undersigned confirms that all necessary consents have been obtained for the collection, use, and disclosure of such information for the purposes of assessing the application for insurance, and if applicable, investigating and settling claims, detecting and preventing fraud, and acting as required or authorized by law.

·  For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Liberty Mutual Insurance Company’s insurance business in Canada.

NAME: / TITLE:
SIGNATURE: / DATE:
(Principal, Partner, or Officer)

Note: This application must be reviewed, signed and dated by a principal, partner or officer of the applicant firm.

A&E Professional Liability (02/13) Page 1 of 7 Application for Insurance

Liberty International Underwriters, a Division of the Liberty Mutual Insurance Company