Professional Liability

Please complete the survey to the best of your ability. Through this survey, we effectively encompass all market shops

Name of Applicant *

Applicant Address *

State *

Zip Code *

Applicant Website Address

Date of formation *

What is your scope of work?

Please note: For purposes of this application, “you/your” includes the Applicant and any other persons or entities seeking coverage under this insurance on whose behalf the Applicant is authorized to submit the following information. Loss and Claim have the meanings as defined in the policy form. If you do not have a copy of the policy form, please obtain from one your insurance advisor.

Have you been involved in a merger, acquisition, or consolidation with another entity in the last 12 months? *

Yes

If yes, please provide additional details of acquisition, or consolidation with another entity in the last 12 months.

1#Name
1#Address of the merged/acquired entity
1#Date of the merger/acquisition

Are you owned by or do you have any controlling interest in another entity? *

Yes

If yes, please provide additional details any controlling interest in another entity.

2#Name
2#Address of the entity
2#Percentage of ownership interest %

Do you or any related entity have any ownership in any other company providing construction or design services?

Yes

If yes, please provide additional details of any ownership in any other company providing construction or design services?

3#Name
3#Address of entity
3#Percentage of ownership interest %

Do you provide any services on any project or for any entity in which you or any related entity has any ownership greater than 20%? *

Yes

If yes, please provide additional details of any services on any project or for any entity in which you or any related entity has any ownership greater than 20%?

4#Project
4#Services provided
4#Percentage of ownership %

Professional Liability Coverage

Limit of Liability Desired

Deductible Desired

Sub Consultants Information

In the last completed year, have you engaged or hired any sub consultants for any of your projects? *

Yes

If yes, please list what professional disciplines are subcontracted below:

a.
b.
c.

In the last completed year, were any of your professional billings paid to sub consultants? *

Yes

If yes, what percentage % of your billings were paid to sub consultants?

Do you require professional liability insurance from sub consultants? *

Yes

Organizational Structure

Please specify your total number of employees below (full and part time employees, including registered, licensed design professionals):

Total number of your employees: Principals

1#Estimate of Employees
1#Registered/Licensed

Total number of your employees: Licensed Design Professionals

2#Estimate of Employees
2#Registered/Licensed

Total number of your employees: Other Technical Consultants

3#Estimate of Employees
3#Registered/Licensed

Total number of your employees: Other(please specify

4#Estimate of Employees
4#Registered/Licensed

1:- Please provide the following information about the applicant’s key employees.

1:- Name in full of ALL partners/ principals/key employees
1:- Professional qualifications
1:- Date qualified
1:- How long in practice?
1:- How long as partner/ principal?

2:- Please provide the following information about the applicant’s key employees.

2:- Name in full of ALL partners/ principals/key employees
2:- Professional qualifications
2:- Date qualified
2:- How long in practice?
2:- How long as partner/ principal?

3:- Please provide the following information about the applicant’s key employees.

3:- Name in full of ALL partners/ principals/key employees
3:- Professional qualifications
3:- Date qualified
3:- How long in practice?
3:- How long as partner/ principal?

Locations

Do you perform all of your services in the Unites States or within United States territories?

Yes

Do you perform any of your services in the following states, please put the details in the respective state box with percentage % of work.

Arizona %
California %
Florida %
Illinois %
New Jersey %
New York %
Texas %
Washington %
West Virginia %
Other %

Do you perform any services internationally, outside of the Unites States? *

Yes

If yes, please list and provide details of all international locations where you perform services below:

1:-Total number of employees.

1#US/Canada
1#UK
1#Other Countries
1#Total

2:- Total sales or revenue $ for the last completed year.

2#US/Canada $
2#UK $
2#Other Countries $
2#Total $

3:- Total revenue $ , sales from online sales or services.

3#US/Canada $
3#UK $
3#Other Countries $
3#Total

Revenue Information

Please complete the revenue information requested below:

1:- Professional Billings

1#Last Completed Year $
1#Prior Two Years $
1#Upcoming Year Projection $

2:-Direct Reimbursables

2#Last Completed Year $
2#Prior Two Years $
2#Upcoming Year Projection $

3:-Other Professional or Technical Fees (please specify):

3#Last Completed Year $
3#Prior Two Years $
3#Upcoming Year Projection $

Billings

Please provide the approximate percentage 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)

Professional Services Areas

Please describe the percentages % of the following professional services the applicant provided last completed year.

Aerospace engineering %
Architecture %
Chemical engineering %
Civil engineering %
Construction management (agency) %
Construction management (at risk) %
Electrical engineering %
Environmental engineering %
General contracting %
HVAC engineering %
Land surveying %
Landscape architecture %
Machine, equipment, and/or m anufacturing %
Marine engineering %
Mechanical engineering %
Nuclear engineering %
Process engineering %
Soil engineering %
Structural engineering %
Other please specify %

Project Information

Please provide us with a breakdown of your projects by type in %.please fill out the applicable.

Airports %
Amusement rides %
Apartments %
Arenas/stadiums %
Bridges %
Condos/townhouses %
Convention centers %
Dams %
Harbors/piers %
Hospitals/healthcare %
Hotels/motels %
Industrial waste treatment %
Jails %
Landfills %
Libraries %
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 %
Renovations ( all including condo) %
Retail structures %
Schools/colleges %
Sewage systems %
Sewage plants %
Superfund/pollution %
Telecommunications %
Theatres %
Tract homes / subdivisions %
Tunnels %
Underground storage tanks %
Utilities %
Warehouses %
Wastewater treatment plants %
Water systems %

Please include a list of the applicant firm’s five (5) largest jobs or projects during the past three (3) years. Please provide the following information:

Applicant firm’s Project#1

1#Project/Client Name
1#Nature of the Services
1#Revenue Obtained $

Applicant firm’s Project#2

2#Project/Client Name
2#Nature of the Services
2#Revenue Obtained $

Applicant firm’s Project#3

3#Project/Client Name
3#Nature of the Services
3#Revenue Obtained $

Applicant firm’s Project#4

4#Project/Client Name
4#Nature of the Services
4#Revenue Obtained $

Applicant firm’s Project#5

5#Project/Client Name
5#Nature of the Services
5#Revenue Obtained $

Client Information

Please indicate the percentage of work performed for the following:

a. Federal Government %
b. State Local Government %
c. Other Contractors %
d. Developers, Companies, Organizations %
e . Private Individuals %
f. Other ( please specify %

What percentage % of your work is attributable to repeat clients?

Insurance Information

Do you currently purchase Professional Liability or Errors and Omissions Insurance?

Yes

If yes, please provide the following information of purchased Professional Liability or Errors and Omissions Insurance for the past three years:

1. Insurance Carrier
2. Type of Coverage
3. Term (MM/DD/YY to MM/DD/YY)
4. Retroactive Date
5. Limits $
6. Deductible $
7. Premium $

What minimum limits do you require for professional liability?

Claims Details

Does any person or entity to be insured have knowledge or information of any act, error, or omission which might reasonably be expected to give rise to a claim or potential claim against him/her or the entity?

Yes

If yes, please explain: any person or entity to be insured have knowledge or information of any act, error, or omission which might reasonably be expected to give rise to a claim or potential claim against him/her or the entity?

After inquiry, have any claims been made against any proposed Insured(s) during the past ten (10) years?

Yes

If yes, please explain: have any claims been made against any proposed Insured(s) during the past ten (10) years?

If yes to any of the above claims details questions, please specify details below and/or submit additional information to Team@litespeedins.com .

a. Standard Industry (AIA, AGC, BIA etc) %
b. Firms Own Contract %
c. Client Contract %
d. Purchase Order %
e. Oral Contracts %

a. imitation of liability clauses under $250,000
b. Alternative dispute resolution clauses, such as mediation?
c. Waiver of consequential damages provisions?