Contractors Professional Liability Protection Claims-Made ...



| |CONTRACTORS PROFESSIONAL LIABILITY PROTECTION |

| |CLAIMS-MADE APPLICATION |

THE INFORMATION BEING REQUESTED 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 PROVIDES CLAIMS-MADE COVERAGE FOR COVERAGE A - CONTRACTORS PROFESSIONAL LIABILITY. FOR SUCH COVERAGE, DEFENSE EXPENSES ARE PAYABLE WITHIN, AND ARE NOT IN ADDITION TO, THE LIMITS OF INSURANCE. IF COVERAGE B - CONTRACTORS INDEMNITY FOR DESIGN PROFESSIONAL'S LIABILITY IS INCLUDED, SUCH INSURANCE PROVIDES CLAIMS-MADE AND REPORTED COVERAGE, AND ATTORNEY'S FEES AND RELATED EXPENSES ARE NOT PAYABLE UNDER SUCH COVERAGE.

IT IS IMPORTANT THAT YOU READ ALL OF THE PROVISIONS OF YOUR POLICY CAREFULLY.

Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise.

An Additional Information section is provided at the end of this document for any information that exceeds the space provided.

GENERAL INFORMATION

|Proposed First Named Insured & Other Named Insured(s): |Today's Date: |

|      |      |

|Mailing Address: |

|      |

|Telephone Number: |Web Address: |

|      |      |

|Type of Legal Entity: |

|      |

|Proposed Effective Date (mm/dd/yyyy) |Proposed Expiration Date (mm/dd/yyyy) |Date Business Started: |

|      |      |      |

|Agent/Broker Name |Contact Person |Telephone Number: |

|      |      |      |

|Agent Address |Email Address |Applicant Home State: |Surplus Lines License #: |

|      |      |   |      |

REQUIRED ATTACHMENTS

Include the following with the submission:

Statement of qualifications package, include resumes of key professional personnel.

Currently valued past five years professional liability loss history.

Subcontracted form(s) utilized (representative of most subcontracted work and expected to be used on subcontractors performing professional service(s)).

Work in Progress list.

Representative contract forms, if applicable.

COVERAGE INFORMATION

|1. |Coverage Request: |

| |Limits |Effective Date |Retroactive Date |Deductible - Coverage A |SIR - Coverage B |

| |      |      |Coverage A: |      |      |      |

| | | |Coverage B: |      |      |      |

|2. |Alternative Coverage Request: |

| |Limits | | |Deductible - Coverage A |SIR - Coverage B |

| |      | | |      |      |

| | | | |      |      |

GEOGRAPHIC AREA OF OPERATIONS

|3. Domestic: |      |% |List key states: |      |

|4. Canada: |      |% |List provinces: |      |

|5. Foreign: |      |% |List countries: |      |

OPERATIONS INFORMATION

|6. |Complete description of operations, scope of work:       |

| | |

|7. |Year each proposed named insured was established: |      |

|8. |Describe any mergers, public acquisitions, consolidations or divestitures since each proposed Named Insured:       |

| | |

|9. |Describe any discontinued operations, including joint ventures: |

| |      |

| |      |

ACCOUNTING YEAR DATA INFORMATION

|10. | | |Estimate for Next 12 Months |Actual for Past 12 Months |

| | | | | |

| | |Dates of Reporting Period: | | |

| | | |      |      |      |      |

| | | |Estimated Construction |Estimated |Actual Construction |Actual Professional |

| | | |Revenues for Reporting |Professional |Revenues for Reporting |Fees |

| | | |Period |Fees |Period | |

| |A |Insured Designs with Construction |      |      |      |      |

| | |Responsibility | | | | |

| |B |Insured Subcontracts Design with |      |      |      |      |

| | |Construction Responsibility | | | | |

| |C |Insured Designs without Construction |      |      |      |      |

| | |Responsibility | | | | |

| |D |Construction Only – No Design |      |      |      |      |

| |E |Construction Mgmt. – Agency |      |      |      |      |

| | |Construction Mgmt. – At Risk |      |      |      |      |

| |F |Wrap Up Projects with Specific Project |      |      |      |      |

| | |Professional Policies | | | | |

| |G |Wrap Up Projects without Specific Project |      |      |      |      |

| | |Professional Policies | | | | |

| |H |Other Professional Services |      |      |      |      |

| | |TOTAL |      |      |      |      |

11. Have you been involved in any Residential Wrap-Ups projects in the past five years? Yes No

|If yes, please explain: |      |

| |      |

12. List your most recent year’s number of projects, by size:

|Construction Value |Number of Projects |

|Up to $10,000,000 |      |

|$10,000,000-25,000,000 |      |

|25,000,000-100,000,000 |      |

|More than 100,000,000 |      |

|Total |      |

DISCIPLINES OF SERVICE OR OPERATIONS INFORMATION

13. Please break down the total revenue show in #10 above by the professional services or operations shown below.

|Types of Services or Operations |% Direct |% Subcontracted |

|Professional Services | | | | |

|Architecture |      |% |      |% |

|Chemical Engineering |      |% |      |% |

|Civil Engineering |      |% |      |% |

|Construction Management - Agency |      |% |      |% |

|Construction Management - At Risk |      |% |      |% |

|Electrical Engineering |      |% |      |% |

|Environmental Engineering |      |% |      |% |

|Geotech/Soil Engineering |      |% |      |% |

|HVAC Engineering |      |% |      |% |

|Interior Design |      |% |      |% |

|Laboratory Testing |      |% |      |% |

|Land Surveying |      |% |      |% |

|Management Consulting |      |% |      |% |

|Mechanical Engineering |      |% |      |% |

|Mining Engineering |      |% |      |% |

|Naval/Marine Engineering |      |% |      |% |

|Process Engineering |      |% |      |% |

|Structural Engineering |      |% |      |% |

|Traffic Engineering |      |% |      |% |

|Other (explain) |      |% |      |% |

|Contracting |

|Carpentry |      |% |      |% |

|Demolition/Dismantling |      |% |      |% |

|Drilling |      |% |      |% |

|Electrical |      |% |      |% |

|Excavation Grading/Site Prep |      |% |      |% |

|General Contracting |      |% |      |% |

|Heavy Highway/Bridge |      |% |      |% |

|HVAC |      |% |      |% |

|Mechanical |      |% |      |% |

|Industrial Cleaners (incl. Sewer/Septic) |      |% |      |% |

|Insulation |      |% |      |% |

|Masonry/Concrete |      |% |      |% |

|Marine |      |% |      |% |

|Oil Lease |      |% |      |% |

|Painting |      |% |      |% |

|Pile Driving |      |% |      |% |

|Pipeline Construction/Cleaners |      |% |      |% |

|Plumbing |      |% |      |% |

|Roofing |      |% |      |% |

|Steel Erection |      |% |      |% |

|Street and Road Construction |      |% |      |% |

|Tunnel |      |% |      |% |

|Other (explain) |      |% |      |% |

|Specialty Services |

|Foundation, Sheeting or Shoring Design |$ |      |      |% |

|Inspections of Commercial Properties |$ |      |      |% |

|Security Design Consulting |$ |      |      |% |

|Plant Monitoring |$ |      |      |% |

|TOTAL |$ |      |100 |% |

ALLOCATION OF GROSS REVENUES INFORMATION

14. Give the percentage of gross revenue of work held under contract, subcontracts, or as duties to fulfill scope of work for which you hold direct or supervisory responsibility:

|a. Acts as a general contractor |      |% |

|b. Acts as an at risk construction manager |      |% |

|c. Acts as an agency construction manager |      |% |

|d. Acts as a subcontractor |      |% |

|e. Design or consulting services (for work other than environmental/pollution remediation) |      |% |

|f. Design or consulting services for environmental/pollution remediation |      |% |

STAFF INFORMATION

|15. |Total Construction |Licensed Engineers or |Registered Surveyors |Project Managers |Supervisors or Foremen |Other |

| |Personnel |Architects | | | | |

| |      |      |      |      |      |      |

CLIENTS/PROJECTS/SERVICES DATA INFORMATION

16. Is your company or any subsidiary, predecessor, or other organization related to your company engaged in:

a. Real Estate Development? Yes No

b. 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. (Total of all percentages must equal 100%.)

|Airports |

|TOTAL (All percentages must add to 100%) |100% |

|17. What percentage of your firm's revenue is derived from repeat clients? |      |% |

|18. What percentage of your firm's revenue is derived from your largest client? |      |% |

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

20. Do you provide any of the following services?

a. Website design or website programming Yes No

b. Database design or management, data warehousing, data application hosting Yes No

c. Maintenance of computer programs, applications or systems designed or developed by you Yes No

d. Design and/or development of computer software programs, systems, or applications Yes No

e. Creation, maintenance, use, modification, input into any digital model or digital representation Yes No

CONSTRUCTION MANAGEMENT INFORMATION

21. Do you perform construction management services? Yes No

Construction Management Services, which you perform:

(Estimated billable fees to others and include all internal allocations for work you self perform):

|a. Cost Management: |$ |      |

|b. Scheduling/Project Coordination: |$ |      |

|c. Constructability Reviews: |$ |      |

|d. Inspections: |$ |      |

|e. Testing: |$ |      |

|f. Other (describe fully): |      |

22. Do you, any subsidiary or related entity, perform construction activities for projects for which you

also perform construction management services? Yes No

23. When performing construction management services, do you assume responsibility for site safety? Yes No

24. When performing construction management services, do you contract directly with the contractors

responsible for construction? Yes No

DESIGN BUILD INFORMATION

25. Do you perform work under design/build contracts? Yes No

| |If yes, what type of projects have you been involved in?      |

26. When performing work under a design/build contract:

a. Are you the architect/engineer/designer of record? Yes No

b. Are you directly performing any architect, engineer or design services? Yes No

27. Do you perform environmental/pollution remediation design services or handling, containment or

disposal protocols for others? Yes No

| |If yes, please describe:      |

SUBCONTRACTORS - PROFESSIONAL LIABILITY INFORMATION

28. If you subcontract design services, please indicate the names of the architect or engineer that you most often use and their

| |professional liability carrier and limits:       |

29. Do you secure certificates of insurance from the architect/engineering subcontractors evidencing their

professional liability coverage? Yes No

30. Do you have minimum limits of professional liability coverage required to be carried by architect/engineering

subcontractors? Yes No

|If yes, minimum limit required? |      |

31. Does your certificates of insurance program maintain current in-force certificates of architect/ engineering subcontractor’s professional liability insurance for their work for you that has been completed? Yes No

|If yes, how long? |      |

32. Does your certificates of insurance program require notice of cancellation, non-renewal, or material

change of the architect/engineering subcontractor’s professional liability insurance for all of their

current work for you and all of their work for you that has been completed? Yes No

33. Does your subcontract require the architect/engineering subcontractor to indemnify you for loss

resulting from their acts, errors or omissions? Yes No

34. Do you require that you be named as additional insured on your subcontractor GL policies? Yes No

|35. What percentage of your firm’s professional services is performed under written contracts? |      |% |

Type of contract used:

|a. |a. U.S.: AIA or AGC standard forms of agreement |      |% |

|b. |b. Canada: ACEC, CCAC or CCDC standard forms of agreement |      |%%|

|c. |c. International: FIDIC standard forms of agreement |      |% |

|d. |d. Other (please specify) |      |% |

36. How are client and/or subcontract agreements reviewed and negotiated? Please check all that apply.

Attorney – Outside Insurance Broker or Agent Reviews

Attorney – In-House Other

| Staff: |Name: |      |Authority level within your firm: |      |

37. Do you provide Value Engineering Services?

a. Directly Yes No

b. Subcontracted Yes No

If yes, describe any projects that were high tech, or involved radically designed products:

|      |

|38. How long do you keep a copy of specs for the job, as well as all RFIs and change orders? |      |

39. Are all products and material modifications documented and approved in writing by the owner,

architect and engineer, and subcontractors? Yes No

40. Do the personnel involved in Value Engineering have the certified quality engineer designation? Yes No

RISK CONTROL INFORMATION

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

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

|43. How often are those procedures updated? |      |

44. Do you utilize written, in-house health and safety procedures? Yes No

45. Are formal change order provisions utilized? Yes No

46. List professional society memberships:

AGC ABC NUCA ASSE DBIA CFMA CMMA

| Other (please specify): |      |

HISTORY INFORMATION

47. Do you currently maintain contractors professional liability insurance coverage? Yes No

If previous coverage has been purchased, please complete history below:

Contractors Professional Liability Coverage History:

|Year |Carrier |Occurrence or |Retroactive Date (if|Limits |Deductible/ |Incurred claims: |Premium |

| | |Claims-Made |applicable) | |SIR |Paid and | |

| | | | | | |Reserved | |

|      |      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |      |

|      |      |      |      |      |      |      |      |

|Date that uninterrupted claims-made Contractors Professional Liability insurance began: |      |

48. Are any coverage limits purchased under the previous coverage that is subject to the requested retroactive date

LESS THAN the coverage limit being applied for? Yes No

|If yes, please explain:       |

49. Have you ever been declined for contractors professional liability insurance, or has any

such coverage ever been cancelled, or non-renewed? Yes No

|If yes, please explain:       |

50. Are you aware of any circumstances or incidents which may result in a claim being filed against any

proposed named insured company? Yes No

|If yes, please explain:       |

CURRENT OTHER LIABILITY INSURANCE PROGRAM INFORMATION

|51. | |Carrier |Retroactive Date |Limits and |

| | | |(if applicable) |Deductible/SIR |

|Commercial General Liability |      |      |      |

|Is coverage currently with or being quoted by | | | |

|Travelers? | | | |

|Yes No | | | |

|Local Travelers U/W Contact: | | | |

|      | | | |

|Umbrella/Excess Liability |      |      |      |

|Contractors Pollution Liability |      |      |      |

|Occurrence Claims-Made | | | |

CLAIM REPORTING INFORMATION

52. What are your claim reporting and investigating procedures for professional liability claims or incidents?

|      |

| |

| |

53. 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 professional liability claim. If none, please indicate this in your response.

|      |

| |

| |

NETWORK AND INFORMATION SECURITY LIABILITY (NAISL)

54. Within the past 2 years, has any proposed named insured:

a. Sustained any systems intrusion, virus attack, hacking incident, data theft, or similar event? Yes No

b. Notified clients or employees that their information may have been comprised? Yes No

|If yes, please describe damage caused and corrective action taken:       |

| |

55. Do you have any knowledge or information of any fact, circumstance, or incident that has resulted in a dispute or claims or may reasonably be expected to result in a claim against you or your subsidiaries? Yes No

56. Is a login ID and password (authentication) required to access secure areas of your website?

N/A - Website is informative only Yes No

57. Do you have a firewall installed or configured to protect your network? Yes No

58. Do you have a company policy for the securing confidential information on both internal computer

systems and also portable communications devices (laptop, BlackBerry, etc)? Yes No

59. Does this policy require that information stored on portable communication devices (laptop, BlackBerry, etc)

be encrypted? Yes No

|60. How frequently do you run anti-virus software and is it run on the following?      |

Yes No Desktops/laptops

Yes No Network gateways

Yes No Mail servers

Yes No File servers

|Other:       |

For information about how Travelers compensates independent agents, brokers, or other insurance producers, please visit this website:



If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers, Enterprise Development, One Tower Square, Hartford, CT 06183.

This application, including any material submitted in conjunction with the application or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by Travelers.  It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond.  Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law.  Availability of coverage referenced in this document can depend on underwriting qualifications and state regulations.

FRAUD STATEMENTS

ARKANSAS, LOUISIANA, NEW MEXICO, RHODE ISLAND, VERMONT AND WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. 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.

DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

HAWAII: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

KANSAS, OREGON: Any person who knowingly and with intent to defraud or solicit another to defraud an insurer: (1) by submitting an application, or (2) by filing a claim (a written application or claim in Kansas) containing a false statement as to any material fact, may be violating state law.

KENTUCKY, MASSACHUSETTS, PENNSYLVANIA: 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.

MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, and denial of insurance benefits.

MARYLAND: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NEW JERSEY: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NEW YORK: 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

OKLAHOMA: WARNING:  Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

UTAH: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and civil penalties.

SIGNATURES

|Authorized Representative Signature*: | Authorized Representative Name - Printed |Date: |

|x      |      |      |

|Producer Signature*: |State Producer License No (required in FL): |Date: |

|x      |      |      |

* If you are electronically submitting this document, apply your electronic signature to this form by checking the Electronic Signature and Acceptance box below. By doing so, you agree that your use of a key pad, mouse, or other device to check the Electronic Signature and Acceptance box constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as a signature affixed by hand.

Electronic Signature and Acceptance – Authorized Representative

Electronic Signature and Acceptance – Producer

ADDITIONAL INFORMATION

This area may be used to provide additional information to any question. Please reference the question number.

     

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