Architects and Engineers PLI Application Form

A detailed underwriting questionnaire that lets insurers evaluate an architecture or engineering firm's revenue history, contracts, subconsultants, and prior claims before issuing a professional liability policy.

Use this template

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Firm Name

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Date Firm Commenced Operations

Federal Tax ID #

Website

Insurance Contact

Title

Phone Number

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3. Has the applicant or any subsidiary in the past three years been involved with, or contemplated in the next 12 months any merger,acquisition or divestment? If yes, please describe details in question #21.

Yes No

*Last Full Fiscal Year

*Land Surveying - Other

*Other #1

*Other #2

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7a. Have you ever provided services outside the USA, its territories and possessions and Canada?

Yes No

7b. What percent of your firm's annual Gross Revenues for the past year was derived from projects outside the USA, its territories and possessions and Canada?

If Yes, please provide details

8. What percent of your firm annual gross revenues for the past year was derived from each of the following categories of Owners? Total = 100

9. What percent of your firm annual gross revenues for the past year was derived from each of the following categories of clients? Total = 100

If any portion of your projects do not fit well into the categories provided above (Misfits), please enter percent of Gross Revenues below:

Attach a list of your firm's 5 largest current projects; include 1) project name, 2) client name, 3) project location, 4) project description, 5) services you are providing, 6) your estimated total gross receipts for the project, 7) estimated project construction value and 8) estimated year the project will be completed.

Max 10 MB per file

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Please attach a copy of your firm's standard contract.

Max 10 MB per file

b) Estimate the percentage of your gross revenues for the past fiscal year was derived from repeat clients?

c) What percentage of the work performed by subconsultants is performed underwritten contracts?

d) When you hire subconsultants, for what percentage of those projects do you obtain professional liability certificates of insurance from your Subs?

Please attach Subconsultant insurance certificates for your 3 largest Subsconsultants

Max 10 MB per file

e) What percentage of your professional services contracts with clients have a limitation of liability clause?

f) What percentage of your firm's current contracts contain a limitation of liability % clause less than or equal to $250,000?

g) Does your firm have non-standard contracts reviewed by legal counsel or your insurance provider for liability implications prior to signing?

Yes No

h) What percent of your Gross Revenues was derived from projects utilizing BIM or virtual design and construction modeling?

i) What percent of your Gross Revenues are on projects designed to meet a Green Building LEED certification?

j) Does your firm provide continuing education and training programs for its professional and technical staff?

Yes No

k) What percent of your firm's licensed staff have participated in risk management training in the last fiscal year?

l) Are any principals or employees of your firm members of any professional associations? (AIA, ASCE, ACEC, NSPS, etc.)

Yes No

a) In the past three years have you brought suit to collect any fees?

Yes No

b) Has your firm or any subsidiary or predecessor firm ever filed for or been in receivership or bankruptcy under Chapter 7 or Chapter 11?

Yes No

c) Does your firm (or any related firm) perform actual construction, erection or fabrication?

Yes No

d) Does your firm (or any related firm) engage in computer software development for or sale to others?

Yes No

e) Does your firm (or any related firm) engage in Real Estate Development?

Yes No

f) Does your firm (or any related firm) engage in the manufacture, sale, leasing or distribution of any product or production process?

Yes No

g) Do you or any principal, owner or officer, director or an immediate family member have an ownership interest in any entity for whom professional services are being rendered?

Yes No

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Architects and Engineers PLI Application Form

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