QUESTIONNAIRE FOR ARCHITECHTS & ENGINEERS PROFESSIONAL LIABILITY INSURANCE QUOTE*
Name of Firm
Date Established
Entity Type
Select
Individual
Partnership
LLC
Corporation
Trust
Joint Venture
Other
Mail Address
County
E-mail
Phone
Fax
Web Site
Branch Office 1 Address
Branch Office 2 Address
Branch Office 3 Address
PERSONNEL
SPECIFY PERSONNEL PER CATEGORIES
NUMBER
# REGISTERED / LICENSED
FULL TIME
PART-TIME
A. Principals, Partners, Officers & Directors:
B. Architects:
C. Engineers:
D. Land Surveyors:
E. Technical Personnel:
F. Other: (administrative/clerical)
G. Total Personnel
GROSS RECEIPTS TO INCLUDE REIMBURSABLE EXPENSES AND FEES PAID TO SUBCONSULTANTS.
Gross receipts attributable to:
Current Fiscal Yr
Ending: (mo/Yr)
Last Fiscal Year Ending: (mo/yr)
Two Years Ago Ending:
(mo/yr)
Three Years Ago Ending: (mo/yr)
a. Separately insured projects
b. Permanently abandoned projects
c. All other fees/ billings
d. Total Gross Receipts (a+b+c)
e. Estimated Gross Receipts for next year $
PROFESSONAL DISCIPLINES
SPECIFY AS A PERCENTAGE OF THE FIRM'S GROSS RECEIPTS. (THE TOTAL SHOULD EQUAL 100%)
Architecture
%
Landscape Architecture
%
HVAC
%
Civil Engineering
%
Land Surveying
%
Fire Protection Engineering
%
Mechanical Engineering
%
Construction/Project Management
%
ConstructionMaterials Testing
%
Electrical Engineering
%
Process Engineering
%
Mining Engineering
%
Structural Engineering
%
Chemical Engineering
%
Interior Design
%
Soils Engineering
%
Environmental
%
Land Use Planning
%
Labratory Testing
%
Hydrogeology/Geology
%
Other
%
SERVICES
PROJECTS
PERCENT OF GROSS RECEIPTS (MUST TOTAL 100%)
AS A PERCENTAGE OF GROSS RECEIPTS (MUST TOTAL 100%)
A. Design / Studies:
%
G.a Schools, colleges
A1. Design with Construction observation / review
%
Gb. Hospitals, retirement or convalescent homes
A2. Design without construction ovservation / review
%
Gc. Hotels, motels or resort properties
A3. Studies, planning, permitting
%
Gd.Condominiums/ Townhouses
B. Construction Related Services:
%
Ge. Residential subdivions/Tract Homes
B1. Construction Managemetn Services (Agency)
%
Gf. Custom single family residential
B2. Construction Management Services (At risk)
%
Gg. Remodel only -single home
B3. Project Management
%
Gh. Apartments
B4. Construction ovservation / review without design
%
Gi. Office / Commercial / Retail
C. Surveying:
%
Gj. Government / Public Building
C1. Construction Staking
%
Gk. Industrial process
C2. Topographic / Boundary Surveys
%
Gl. Machine design
C2. Other
%
Gm. Sports Stadiums / Amusement Parks
D. Inspections as Stand-Alone Service:
%
Gn. Public Utilities / Power Generation
D1. Construction Inspection
%
Go. Jails / Justice
D2. Real Estate Pre-Acquisition
%
Gp. Airports
D3. Mold Inspection/Investigation
%
Gq. Roads / Highways / Traffic
D4. Water Intrusion Inspection
%
Gr. Seewage or waste disposal systems
E. Miscellaneous Services:
%
Gs. Water systems
E1. Forensic / Expert Witness
%
Gt. Wastewater Treatment Plants
E2. Plan Checking
%
Gu. Pipelines
E3. Quantity / Cost Estimating
%
Gv. Dames / reservours / mines / quarries
E4. Drafting (stand alone service without design)
%
Gw. Harbors, jetties, docks or piers
E5. Other
%
Gx. Bridges, tresles or tunnels
TOTAL SERVICES HERE SHOULD = 100%
Gz. Falsework/Shoring/Temporary Structures
CLIENTS -PERCENT MUST EQUAL 100%
H. In the past five years has your firm, a predecessor firm or any other insured provided any services on residential condominium or townhouse projects? If, yes please provide details and complete the following?
Fa. Government or Public Entities
Fb. Owners acting as their own builders
Fc. Design/Build or turnkey contractors
Fd. Other Contractors
Total number of Condominium / Townhouse Projects?
Fe. Developers
Ff. Financial and lending Institutions
Approximate total construction value? $
Fg. Other design professionals
What percentage of the firm's projects are outside the U.D. and Canada?
%
Fh. Insurance Companies/ Attorneys
TOTAL SHOULD EQUAL 100%
%
Fi. Other
Which Countries? List
What percentage of Total Gross receipts reported above are from repeat clients Total here 100%
CONTRACTS
PLEASE SPECIFY TYPES OF CONTRACT USED BY THE FIRM. (MUST TOTAL 100%)
a. Standard Industry contract(AIA, EJCDC<ASFE,etc)
%
e. Client contract
b. Firm's own standard contract
%
f. Oral agreement
c. Letter agreement
%
g. Other (if other explain)
d. Purchase order
%
What percentage of the firm's contracts contains a Limitation of Liability Clause?
FINANCIAL AND OTHER INTEREST
Does the firm have any predecessor firms or related entities? If yes list all pre-existing entities, including mergers and their dates of existence. List
Please select
Yes
No
FOR ALL "Yes" responses please prove details.
During the past 12 months has the firm or any principal:
a. Engaged in the actual construction or hired a construction Contractor to perform construction work?
Please select
Yes
No
If yes please explain:
b. Become involved with or have ownership interest in a construction or Real Estate Development Company?
Please select
Yes
No
If "yes" please explain:
c. Been employed by an officer of any other firm, organization or political body?
Please select
Yes
No
If "yes" to c. please explain
d. Derived more than 50% of last fiscal year's gross receipts from any one client?
Please select
Yes
No
If "yes" to d. please explain:
e. Designed e building, component or system which mighet be used on more than one project?
Please select
Yes
No
If "yes" to e., please explain:
f. Become Involved in the manufacture or fabrication of any component, devie or system?
Please select
Yes
No
If "yes" to f., please explain:
g. Provided electronic date processing services for others or sold software components?
Please select
Yes
No
If "yes" to g., please explain:
h. Been teh subject of disiplinary action by authorities as a result of Professional or business activitie?
Please select
Yes
No
If "yes" to h., please explain:
HAS THE FIRM ANY JOINT VENTURES
a. Has the firm entered into any Joint Ventures? If yes explain:
Please select
Yes
No
b. Does the firm's Joint Venture agreement profide for allocation of liabilities?
Please select
Yes
No
c. Does the firm require evidence of professional liability Insurance from all Joint Venture members?
Please select
Yes
No
If "yes" to a,b or c above will you explain:
A.Does your firm or any principal, partner, officer, director or shareholder of your firm or any immediate family member or any such person have any ownership interest in any entity or project for which professional services have been or are to be rendered?
B.Other than for third party claims, does your firm seek coverage for these projects? If yes and Equity interest supplemental will be sent to you for completion.
C.Does the firm have any Abandoned Projects to be excluded from coverage? If yes, an Abandonded Projects Questionnaire will be sent to you for completion.
SUBCONTRACTORS / SUB CONSULTANTS
a. Please provide, as a percentage of the Total Gross Receipts reportin in the questionnaire above, the fees paid to the firms subconsultants in the following disciplines (Should not total 100%)
Architecture
%
Soils
%
Electical
%
Civil
%
Structural
%
If, other (explain)
%
Mechanical
%
HVAC
%
DESCRIBE YOU FIRM'S SUBCONTRACTOR AND SUBCONSULTANT SELECTION PROCESS:
Do you hire subcontractors to perform construction?
Please select
Yes
No
If yes to hired subcontractor to perform work please explain:
Are all contractors and subconsultants hired under a written contract?
Does the firm obtain certificates of insurance from all subcontractors and subconsultants?
Please select
Yes
No
Sometimes
QA / QC ISSUES
Does the firm have an Ownership of Documents clause in each contract for hire? If no, What does the firm do to protect tiself against reuse of its plans and specifications without knowledge or authorization?
Enter Security Code: