Society of Fire Protection Engineers
PROFESSIONAL LIABILITY APPLICATION FORM
(THIS IS AN APPLICATION FOR CLAIMS MADE INSURANCE)
 

This application is for a policy that is limited generally to liability for only those claims that are first made against the insured whilst the policy is in force. Please review the policy carefully and discuss the coverage thereunder with your insurance agent or broker. Describe in the following answers the precise nature of your operation. Please attach a brochure and letterhead of your firm as well as a list of your ten largest jobs.

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4. The Applicant/Firm is: (please check where applicable)
5. Is the Applicant/Firm now, or has it in the past been controlled, owned or associated with any other firm, corporation or company other than stated above?
6. During the past five years has the name of the firm changed or has any other business purchased or any mergers or consolidations taken place?
8. Is the Applicant/Firm involved in any of the following Professional activities? If YES, please complete the following with percentages of gross receipts.
 Fire Protection ServicesOther Engineering Services
a) Design only
b) Design and Build
c) Installation/Construction (only)
d) Installation (without design)
e) Post fire investigation
f) Pre fire inspection
g) Local Authority Employee/Contractor
h) Education/Training
i) Product Design
j) Product Manufacture
k) Fire services
l) Others. Please explain
9. A. Please give the following details of professional personnel.
 Names of Principals, Directors & OfficersQualifications and/or DegreesDate ReceivedYears with firm
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 Names of Other Senior PersonnelQualifications and/or DegreesDate ReceivedYears with firm
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B. Total Personnel
10. A. Please provide examples of your main disciplines of Professional Service. Please provide enough examples to cover most of the work you do. Please show percentages of income derived from each services, together with a description. Please use a separate attachment if necessary.
 

Example ---- 30% ---- Fire protection design.    I/we provide design specifications for industrial clients, mostly light manufacturers.
B. In the past 5 years has there been any significant changes in the answers to Questions 7, 8, and/or 9?
C. Do you foresee any substantial changes in the coming year?
11. Do you sublet or subcontract any professional services to others?
D. Do you always obtain Professional Indemnity Certificates from the subcontractor?
E. Do you ever assume the liability of others by agreement under any contract, whether the contract be written or oral?
12. Do you, or have you ever engaged in any overseas projects?
13. Is more than 30% of your professional services work for any one client?
14. Does the Applicant/Firm or any of its principals, directors or officers, individually or collectively maintain a financial interest in any project or in any client for which the Applicant has rendered professional service?
15. Does your professional work ever involve designs, plans and/or specifications for experimental or untested means of construction?
C. Standard Contract, or identify the Contract Coding if you use an Industry Standard Contract.
17. Do you currently carry professional liability insurance for your firm?
18. Please provide details on your current and two previous Professional Liability policies.
 INSURERPOLICY NO.LIMITSDEDUCTIBLEPREMIUMPERIOD
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19. Has any application for similar insurance made on behalf of the Applicant/Firm, any predecessor in business or present partners/officers ever been declined or has any such insurance ever been canceled or refused?
20. Has any claim(s) or suit(s) relating to Professional Services rendered ever been made against the Applicant/Firm or any entity named in Question 1. or against their predecessors in business, or against any past principal, partner, director, officer or employee or any entity named in Question 1?
21. Is the Applicant/Firm aware of any circumstances which may result in a claim against him/her or any entity named in Question 1, or against their predecessors in business, or against any past or present principal, partner, director, officer or employee of any entity in Question 1?
I am currently a paid up member/associate member of SFPE.
I have recently applied for membership in SFPE on (Date)
 
Coverage Requested

Additional Remarks:

I/We (Applicant/Firm) declare that the above statements and particulars are true and that no facts have been suppressed or misstated and agree that this proposal form shall be the basis of any policy of insurance which may be issued by Underwriters and shall be deemed a part thereof. In addition, Proposer agrees and acknowledges that if Proposer, subsequent to the completion of this proposal, becomes aware of any changes in the statements and particulars contained herein, that Applicant/Firm shall immediately advise Underwriters of such changes. It is further understood and agreed that upon receipt of such supplemental advises, Underwriters may alter or withdraw any quotation previously offered, or amend the terms of or cancel any policy which has been issued based upon that statement and particulars contained herein.

LII 58 AP (03/11)