CONTRACTORS PROFESSIONAL LIABILITY PROTECTION: …



[pic] |ELECTRICAL CONTRACTORS

PROFESSIONAL LIABILITY PROTECTION: CLAIMS-MADE APPLICATION | | |THIS APPLICATION IS FOR A SURPLUS LINES PRODUCT. THE AGENT/BROKER MUST HAVE A SURPLUS LINES LICENSE ISSUED BY THE STATE OF DOMICILE FOR THIS RISK IN ORDER TO RECEIVE A QUOTATION.

This application is for professional liability coverage, which includes a single total (aggregate) limit of coverage and includes defense expense within the limits of coverage.

Mail Original to: Travelers

Construction Specialty, MC SB05Y

385 Washington Street

Saint Paul, MN 55102-1396

|Agency/Broker Name |

|      |

|Agents Address (street, city, state, zip code) |

|      |

|Contact Person |Telephone Number |Email Address |Fax Number |

|      |      |      |      |

1. APPLICANT – AS YOU WOULD WANT TO HAVE IT APPEAR ON THE POLICY:

|Applicant |

|      |

|Address (street, city, state, zip code) |

|      |

2. COVERAGE:

Coverage Request:

|Limits |Effective Date |Retroactive Date |Deductible |

|      |      |      |      |

3. Operations AND TERRITORY

|Description of operations, type of work |

|      |

|Year Established |Any acquisition since company established? (describe) |

|      |      |

|Describe any discontinued operations |

|      |

|Key states of operation |

|      |

|List states in which licenses are held by you List other countries you work in or may work in. |

|            |

List the percentage of your organization’s receipts estimated for the next 12 months from the following types of work.

|Cogeneration |     % |Environmental Systems Control |     % |Cable/Closed Circuit TV work |     % |

|Electric Power Systems |     % |Fiber Optic Cable |     % |Sound Equipment work |     % |

|Emergency Power Work |     % |Telephone Install |     % |Voice Data/Video work |     % |

|Switchgear Installation |     % |Banking equip install |     % |Access Control systems |     % |

|Electronic Controls Installation |     % |Fire/Burglar Alarms |     % |Uninterrupted Power Supply work |     % |

|Computerized Controls Installation |     % |Energy Mgmt Controls |     % |All other electric work |     % |

| | | |TOTAL (Columns must equal 100%) |100% |

4. STAFF

|NO. OF TOTAL STAFF |NO. OF ENGINEERS |NO. OF DRAFTSMEN OR DESIGN TECHNICIANS|NO. OF MASTER ELECTRICIANS |

|      |      |      |      |

5. ACCOUNTING YEAR DATA

| | |ESTIMATE FOR NEXT 12 MONTHS |PAST 12 MONTHS |

| | | | |

| |DATES OF | | |

| |REPORTING PERIOD | | |

| | |      |      |      |      |

| | |ESTIMATED CONSTRUCTION |ESTIMATED |ACTUAL CONSTRUCTION |ACTUAL |

| | |REVENUES |PROFESSIONAL |REVENUES |PROFESSIONAL |

| | | |FEES | |FEES |

|A |INSURED DESIGNS WITH CONSTRUCTION |$      |$      |$      |$      |

| |RESPONSIBILITY | | | | |

|B |SUBCONTRACTED DESIGN WITH CONSTRUCTION |$      |$      |$      |$      |

| |RESPONSIBILITY | | | | |

|C |INSURED DESIGNS WITHOUT CONSTRUCTION |$      |$      |$      |$      |

| |RESPONSIBILITY | | | | |

|D |CONSTRUCTION ONLY – NO DESIGN |$      |$      |$      |$      |

|E |WRAP UP PROJECTS WITH SPECIFIC PROJECT |$      |$      |$      |$      |

| |PROFESSIONAL POLICIES | | | | |

|F |WRAP UP PROJECTS WITHOUT SPECIFIC PROJECT|$      |$      |$      |$      |

| |PROFESSIONAL POLICIES | | | | |

|G |OTHER PROFESSIONAL SERVICES |$      |$      |$      |$      |

| |TOTAL |$      |$      |$      |$      |

|HAVE YOU BEEN INVOLVED IN ANY RESIDENTIAL WRAP UPS IN THE PAST FIVE YEARS? |

|                                                                                           |

6. CLIENTS/PROJECTS/SERVICES DATA

Is your company or any subsidiary, predecessor or other organization related to your company engaged in the

manufacture, sale or distribution of any product or process or patented production process: Yes No

Project Information: List the percentage of your organization’s receipts estimated for the next 12 months from

the following project types. (Columns must equal 100%.)

|Airport excluding runways |      % |Hospitals |      % |Petro/Chemical |      % |

|Airport runways |      % |Hotels/Motels |      % |Power Plant/Public Utilities |      % |

|Apartment |      % |Jails/Prisons |      % |Recreational/Sports |      % |

|Bridges/Harbors/Piers |      % |Manufacturing/Industrial |      % |Retail/Commercial |      % |

|Call Centers |      % |Mass Transit |      % |Schools/Colleges |      % |

|Condominiums |      % |Mines |      % |Street/Highway Lighting or |      % |

| | | | |Traffic Control | |

|Financial Institutions |      % |Mixed Use Residential/Commercial |      % |Other (specify) |      % |

| | | | |      | |

|Homes |      % |Office Buildings |      % | | |

|TOTAL (Columns must equal 100%.) |100 % |

Please provide the following information on your firm’s two (2) largest current projects:

| | | |Project |Services |Total |Estimated |

|Project Name |Location |Owner/Client |Type |Performed |Professional Fees |Construction |

| | | | | | |Value |

|      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |

What percentage of your firm’s revenue was derived from repeat clients?       % From your largest client?       %

Does your insured have a financial/equity interest in any projects? Yes No

7. Design Responsibilities

|Do you have employees who provide design or engineering services? | | Yes No |

|When performing design services are you the architect/engineer/designer of record? | | Yes No |

|Do your employees provide design or engineering services on projects on which you do not do the construction? | | Yes No |

|Do you provide or subcontract out softrware design services? | | Yes No |

|If you subcontract design services, please indicate the names of the A&E that you most often use and their professional liability | | |

|carrier and limits: | | |

|      | | |

|Do you secure certificates of insurance from the architect/engineering subcontractors evidencing their professional liability | | Yes No |

|coverage? | | |

|Minimum limits of professional liability coverage required to be carried by architect/engineering subcontractors? | |      |

|Does your certificates of insurance program maintain current in-force certificates of architect/ engineering subcontractor’s | | Yes No |

|professional liability insurance for their work for you that has been completed? | | |

|If yes, for how long? | |      |

|Does your subcontract require the architect/engineering subcontractor to indemnify you for loss resulting from | | Yes No |

|their acts, errors or omissions? | | |

|What percentage of your firm’s professional services is performed under written contracts? | |     % |

|Type of contract used:      % AIA      %AGC      % Other Please specify       | | |

|Who reviews & negotiates client and/or subcontract agreements? | | |

|Name:       |Position:       | | |

|Do you perform construction management services? If yes, attach a copy of sample contract form(s) | | Yes No |

8. RISK CONTROL

|Do you have a dedicated Risk Manager and/or Safety Officer? | | Yes No |

|Do you utilize written, in-house quality control procedures? | | Yes No |

|Are formal change order provisions utilized? If yes, please provide description of process or procedures. | | Yes No |

|      | | |

|List professional society memberships: NECA IEC ASSE NFPA | | |

| OTHER (please specify):       | | |

9. CURRENT OTHER LIABILITY INSURANCE PROGRAM

Commercial General Liability Is coverage currently with or being quoted by Travelers ? Yes No

| |CARRIER |OCCURRENCE OR |RETROACTIVE DATE |LIMITS AND |

| | |CLAIMS-MADE |(IF APPLICABLE) |DEDUCTIBLE/SIR |

|UMBRELLA/EXCESS LIABILITY |      |      |      |      |

|CPL – CONTRACTORS POLLUTION LIABILITY |      |      |      |      |

|Retroacti:ve Date       | | | | |

10. claim reporting practices

|What are your claim reporting and investigating procedures for professional liability claims or incidents: | | |

|      | | |

|Please describe any professional liability claims that have been made against you, or any individual holding a management or supervisory | | |

|position with you, during the last seven years and any acts, errors or omissions which have been committed during the last seven years, | | |

|which are known, and which could reasonably give rise to such a future claims. If none, please state below: | | |

|      | | |

11. LOSS HISTORY (Attach current loss runs)

|If previous coverage has been purchased, indicate ALL past carriers for the past five years, each limit(s) of coverage purchased, and if| | |

|any of these policies have had a claim submitted under the coverage. | | |

|If yes, specifically explain: | | |

|      | | |

Contractors Professional Liability Coverage History:

| | | | | | |Incurred claims | |

|Year |Carrier |Occurrence or |Retroactive Date |Limits |Deductible/SIR |Paid and |Premium |

| | |Claims-Made | | | |Reserved | |

|      |      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |      |

|Has there been any gap in Contractors Professional Liability Coverage purchased by the applicant between the time of making this application | | Yes No |

|and the requested retroactive date? If yes, specifically explain. | | |

|      | | |

|Are any coverage limits purchased under the previous coverage back to the requested retroactive date LESS THAN the coverage limit being | | Yes No |

|applied for? If yes, specifically explain. | | |

|      | | |

|Has the applicant ever had its policy cancelled, or non-renewed? If yes, specifically explain. | | Yes No |

|      | | |

|Attention: Insureds in AR, CO, DC, HI, KY, LA, MN, NJ, NM, NY, OH, OK, OR, and WV. |

|Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any |

|materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, |

|which is a crime, and may also be subject to a civil penalty. |

| |

|(In New York, the civil penalty is not to exceed five thousand dollars and the stated value of the claim for each such violation.) |

| |

|(In Colorado, any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a |

|policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from |

|insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.) |

|Attention: Insureds in FL |

|Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any |

|materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, |

|which is a felony of the 3rd degree, and may also be subject to a civil penalty. |

|Attention: Insureds in ME, TN, VA, and WA |

|It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties |

|include imprisonment, fines, and denial of insurance benefits. |

|Attention: Insureds in PA |

|Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any |

|materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which|

|is a crime and subjects such person to criminal and civil penalties. |

|Attention: All Other |

|Any person who knowingly and with the intent to defraud any insurance company or another person files an application for insurance containing any materially false|

|information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and |

|subjects the person to criminal and civil penalties. Not applicable in Nebraska. |

|Applicant Signature |Date |

|      |      |

|Agent/Broker Signature |City, State, Zip |Date |

|      |      |      |

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