Society of Fire Protection Engineers Professional Liability

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Society of Fire Protection EngineersPROFESSIONAL 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.

1. A. Name of Applicant/Firm and all past and present entities for whom coverage is sought. If more than one entity is shown, please explain their interrelationship on a separate attachment. *

City *

State *

ZIP *

C. Telephone number

Fax number

D. Website address

E-Mail Address

E. Mailing address

B. Physical Address *

2. In what state is the Applicant/Firm licensed or registered? Please give the percentage of total work in which states.

3. When was the Applicant/Firm established: +

4. The Applicant/Firm is: (please check where applicable)

A. Individual

B. Partnership

C. Corporation

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?

YES

NO

If YES, please give details on a separate attachment.

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?

YES

NO

If YES, please give details on a separate attachment.

7. Please state gross income from services for the past 12 months:

Please give estimate of gross income from services for the next 12 months:

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 Services	Other Engineering Services
a) Design only	Fire Protection Services	Other Engineering Services
b) Design and Build	Fire Protection Services	Other Engineering Services
c) Installation/Construction (only)	Fire Protection Services	Other Engineering Services
d) Installation (without design)	Fire Protection Services	Other Engineering Services
e) Post fire investigation	Fire Protection Services	Other Engineering Services
f) Pre fire inspection	Fire Protection Services	Other Engineering Services
g) Local Authority Employee/Contractor	Fire Protection Services	Other Engineering Services
h) Education/Training	Fire Protection Services	Other Engineering Services
i) Product Design	Fire Protection Services	Other Engineering Services
j) Product Manufacture	Fire Protection Services	Other Engineering Services
k) Fire services	Fire Protection Services	Other Engineering Services
l) Others. Please explain	Fire Protection Services	Other Engineering Services

9. A. Please give the following details of professional personnel.

	Names of Principals, Directors & Officers	Qualifications and/or Degrees	Date Received	Years with firm
.	Names of Principals, Directors & Officers	Qualifications and/or Degrees	Date Received	Years with firm
.	Names of Principals, Directors & Officers	Qualifications and/or Degrees	Date Received	Years with firm
.	Names of Principals, Directors & Officers	Qualifications and/or Degrees	Date Received	Years with firm
.	Names of Principals, Directors & Officers	Qualifications and/or Degrees	Date Received	Years with firm

.

	Names of Other Senior Personnel	Qualifications and/or Degrees	Date Received	Years with firm
.	Names of Other Senior Personnel	Qualifications and/or Degrees	Date Received	Years with firm
.	Names of Other Senior Personnel	Qualifications and/or Degrees	Date Received	Years with firm
.	Names of Other Senior Personnel	Qualifications and/or Degrees	Date Received	Years with firm
.	Names of Other Senior Personnel	Qualifications and/or Degrees	Date Received	Years with firm

B. Total Personnel

i. Other technical staff

ii. Number of office (non-technical staff)

iii. Total construction force, if any

iv. Total of all 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?

YES

NO

If YES, please give details on a separate attachment.

C. Do you foresee any substantial changes in the coming year?

YES

NO

If YES, please give details on a separate attachment.

11. Do you sublet or subcontract any professional services to others?

YES

NO

If YES, please advise the following information:

A. Circumstances in which you would subcontract services.

B. Disciplines you sublet.

C. Percentage of your fees/construction values sublet.

D. Do you always obtain Professional Indemnity Certificates from the subcontractor?

YES

NO

E. Do you ever assume the liability of others by agreement under any contract, whether the contract be written or oral?

YES

NO

12. Do you, or have you ever engaged in any overseas projects?

YES

NO

If YES, please advise the location of the work, nature of your operation and the percentage of your overall work it represents on a separate attachment.

13. Is more than 30% of your professional services work for any one client?

YES

NO

If YES, please advise the percentage of total work and nature of this relationship.

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?

YES

NO

If YES, please advise the nature of the relationship, the percentage of ownership and the percentage of your overall work this represents.

15. Does your professional work ever involve designs, plans and/or specifications for experimental or untested means of construction?

YES

NO

If YES, please advise full details of this work on a separate attachment.

16. A. On what percentage of jobs do you use written contracts?

B. If the answer is less than 80%, please advise why written contracts are not used more frequently.

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?

YES

NO

If YES, please advise the retroactive date of that policy.

18. Please provide details on your current and two previous Professional Liability policies.

	INSURER	POLICY NO.	LIMITS	DEDUCTIBLE	PREMIUM	PERIOD
.	INSURER	POLICY NO.	LIMITS	DEDUCTIBLE	PREMIUM	PERIOD
.	INSURER	POLICY NO.	LIMITS	DEDUCTIBLE	PREMIUM	PERIOD
.	INSURER	POLICY NO.	LIMITS	DEDUCTIBLE	PREMIUM	PERIOD

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?

YES

NO

If YES, please give details. Please use a separate attachment.

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?

YES

NO

If YES, state briefly the cause and nature of the claim including the amount involved, the date when the claim was made, the date the act giving rise to the claim was committed and the final disposition. Please use a separate attachment.

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?

YES

NO

If YES, please give full details on a separate attachment.

I am currently a paid up member/associate member of SFPE.

YES

NO

I have recently applied for membership in SFPE on (Date)

YES

NO NO

Coverage Requested

Limit per Claim

Deductible

Aggregate Limit, Inclusive of Legal Costs

Effective Date

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)