APPLICATION FOR ARCHITECTS, ENGINEERS, AND CONSTRUCTION MANAGERS ERRORS & OMISSIONS INSURANCE (RISKS WITH ANNUAL REVENUES OF $750,000 OR LESS)

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NOTICE: THIS IS A CLAIMS-MADE FORM: EXCEPT TO SUCH EXTENT AS MAY OTHERWISE BE PROVIDED HEREIN, THE COVERAGE OF THIS POLICY IS LIMITED TO LIABILITY FOR ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED AND REPORTED IN WRITING TO THE COMPANY WHILE THE POLICY IS IN FULL FORCE. PLEASE REVIEW THE POLICY CAREFULLY. COVERAGE IS WRITTEN ON A SURPLUS LINES BASIS. RATES SHOWN BELOW ARE FOR APPLICANTS GENERATING GROSS Revenues OF $750,000 OR LESS ANNUALLY AND POSSESSING THE FOLLOWING RISK CHARACTERISTICS: • Does not specialize in structural, geotechnical, bridges, tunnels, dams, petrochemical, nuclear, at-risk CM, cranes, pools,   design-build, elevators, railroads, roofing, or yacht activities   •Not domiciled in SC or WA • Has had no more than two claims in the last 5 years; no more than $20,000 in total incurred losses during the last 3 years
STEP A: DETERMINE PREMIUM based on desired Limits of Liability.            (Contact Fox Point if Revenues exceed $750,000.)
Annual Revenue Under $750,000	Limit of Liability * Deductible FL & CA Other States $ 250,000/$250,000 $5,000 $3,345.00 $3,185.00 $ 500,000/$500,000 $5,000 $4,095.00 $3,900.00 $1,000,000/$1,000,000 $5,000 $5,145.00 $4,900.00	* Other Liability and Deductible options are available.
STEP B: CALCULATE THE TOTAL AMOUNT to be remitted.
Total Premium from Step A: $0.00 + $250.00 Policy Fee (Required) = Total Remittance Amount: $250.00

1.	GENERAL INFORMATION
	Applicant Name:
	dba Name:
	Business Address:
	City:		State:	--Select One-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming	Zip:
	Phone:	() -	Fax:	() -
	Email:			Date Established:
	Website Address:
	In the past five years, has the Applicant ever changed names or been party to any acquisition, consolidation, merger, or dissolution?					Yes No
		If "Yes", please explain

	Please provide the following information about the Applicant’s key employees:
	Name in Full of ALL Partners Principals, or Key Employees	Professional Qualifications	Date Qualified	How long in practice? (Yrs/Months)	How long as a Principal/Partner?
				/	/
				/	/
				/	/
				/	/
	To what professional association(s) does the Applicant belong?

	Please describe the percentages of the following services the Applicant provides/intends to provide:
	Service	Last Year	Current Year	Service	Last Year	Current Year	Service	Last Year	Current Year
	Aerospace Engineering	%	%	General Contracting	%	%	Mechanical Engineering	%	%
	Architecture	%	%	HVAC Contracting	%	%	Nuclear Engineering	%	%
	Chemical Engineering	%	%	Interior Designer	%	%	Process Engineering	%	%
	Civil Engineering	%	%	Land Surveying	%	%	Soil Engineering	%	%
	Construction Management	%	%	Landscape Architecture	%	%	Structural Engineering	%	%
	Electrical Engineering	%	%	Machine, Equipment, Mtg.	%	%	Other (specify):	%	%
	Environmental Engineering	%	%	Marine Engineering	%	%

2.	FINANCIAL AND BUSINESS INFORMATION
	a. Please provide the gross billings for services listed below that were performed by the Applicant:
		LAST 12 MONTHS		PROJECTED NEXT 12 MONTHS
		GROSS Revenues	CONSTRUCTION VALUES	GROSS Revenues	CONSTRUCTION VALUES
	Design	$	$	$	$
	Design/Build	$	$	$	$
	Actual Construction/ Fabrication/Erection	$	$	$	$
	Design	$	$	$	$

	b. Provide approximate percentages of billings derived from the following services. Must equal 100%.
	%	NATURE OF Services OFFERED	%	NATURE OF Services OFFERED
		Feasibility studies, reports, and surveys not resulting in design		Inspections of homes/commercial properties for prospective buyers/lenders
		Design without supervisory services		Inspections of existing structures
		Design and observation		Development, sale, or leasing of computer hardware/software
		Construction/project management		Manufacture, sale, or distribution of any product/service
		Construction observation without design		Other (describe):

3.	CLIENTS
	a. Complete the following for the Applicants 3 largest projects/clients:
		PROJECT/Client Name	Services PROVIDED	Revenues
	1			$
	2			$
	3			$
	c. Does the Applicant follow in-house quality control procedures?			Yes No
	d. Does the Applicant require continuing education for all professional employees?			Yes No
	e. How many professional employees of the Applicant have attended at least six hours of continuing education over the past 12 months?			Yes No

4.	CONTRACTS
	a.	Does the Applicant use written contracts on every project?	Yes No
		If "No", please provide the percentage of projects where oral agreements were used:	%
	b.	Please specify the approximate percentage of professional services rendered under AIA or EJCDC standard contracts:	%
	c.	If non-standard contract, modified AIA/EJCD Ccontracts or letter agreements are used, are they reviewed by the Applicant’s legal counsel prior to signing?	Yes No
	d.	Does the Applicant seek a limitation of liability clause in contracts with clients?	Yes No
		If "Yes", what percentage of contracts contain this clause?	%
	e.	Does the Applicant negotiate into its contracts a provision for alternative dispute resolution such as mediation?	Yes No
		If "Yes", what percentage of contracts contain this clause?	%
	f.	Does the Applicant subcontract any professional services?	Yes No
		If "Yes", please explain

5.	CLAIMS/LOSS HISTORY
	a.	Has the Applicant or any associated professional ever:
	i)	Had a professional license or registration denied, suspended, revoked, non-renewed, or restricted?	Yes No
	ii)	Been formally reprimanded by any court, administrative or regulatory agency?	Yes No
	iii)	Been formally accused of violating any professional association’s code of ethics?	Yes No
	iv)	Been convicted of a felony?	Yes No
	v)	Been involved in or is aware of any fee disputes involving suits?	Yes No
		If the answer to any question under 5a is "Yes", please explain
	b.	Has any Professional Liability claim(s), complaint or proceeding been made against the Applicant or any person or organization proposed for this insurance or any predecessor organization?	Yes No
	c.	Is (are) any person(s) or organization(s) proposed for this insurance aware of any fact, error, omission, circumstance, or situation that might provide grounds for any claim under the proposed insurance?	Yes No
		NOTE: It is understood and agreed that with respect to Questions 5a, 5b, or 5c, that if such knowledge or information exists any claim or action arising there from is excluded from the proposed coverage.

6.	PRIOR INSURANCE
	a. Please provide the following information for any Errors & Omissions or Professional Liability Insurance the Applicant carried during the last three years:
	COMPANY	LIMIT OF LIABILITY	DEDUCTIBLE	PREMIUM	POLICY PERIOD FROM - TO	RETRO DATE*
		$	$	$	-
		$	$	$	-
		$	$	$	-
*Applicants seeking a retro-active date other than the policy effective date should contact Fox Point Programs.
	b. Has any Errors & Omissions or Professional Liability Insurance issued to the Applicant ever been declined, cancelled, or non-renewed?					Yes No
	If the answer is "Yes", please explain

	c. Please provide the following information on the Applicant’s current General Liability coverage:
	INSURANCE COMPANY	TYPE OF COVERAGE	LIMITS		EFFECTIVE
			BI	PD	FROM	TO
			$	$

PAYMENT OPTIONS
	A.	Check For Full Amount Due, Payable to Fox Point Programs, Inc.
	B.	Credit Card:	VISA  Mastercard  AMEX	Card Number:
				Expiration Date:	01 02 03 04 05 06 07 08 09 10 11 12 / 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024
	Applicant Statement & Agreement
			By checking this box, I attest that all information that I have provided on this application or any other document filled out in connection with it is true and correct.  I have withheld nothing that would, if disclosed, affect this application unfavorably.   Checking this box indicates my signature as agreement to these terms.