CONTRACTORS PROFESSIONAL AND POLLUTION LIABILITY APPLICATION
NOTICE: THE CONTRACTORS PROFESSIONAL AND POLLUTION LIABILITY POLICY PROVIDE THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY SETTLEMENTS OR CLEANUP COSTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT.
Instructions 1. 2. 3. 4. Please complete this application. All questions applicable to each coverage applied for must be answered. If space is insufficient to complete answers, please continue on your firm’s letterhead. This form must be signed and dated by an owner, partner or director/officer of your firm. The following information is required: • • • • • • • Application 1. Name_____________________________________________________________________________ Post Office Address__________________________________________________________________ 2. Address of Headquarters______________________________________________________________ Telephone Number of Headquarters _____________________________________________________ Contact and Title ____________________________________________________________________ Fax and E-mail Address ______________________________________________________________ 3. 4. 5. Attach a list of proposed Named Insureds to be covered by this policy (only those entities performing services and/or operations as proposed will be designated as Named Insureds). How long has the Applicant been in business? ______________ During the past five years has the name of the applicant been changed or has any other business been purchased or have any mergers or consolidations taken place (please check): YES NO If yes, give full details (dates, type of purchase (stock, assets): Attach a copy of construction management and/or design build contract Attach SF254 or 10 largest project list Resumes of key personnel Hard copy of loss runs for Professional Liability and Contractors Pollution Brochure/statement of qualifications Safety procedure manual Audited financial statement for last two years
6.
Indicate the total gross revenues for all operations $_____________________.
7.
Total Professional Staff Personnel of Applicant a. Principals _______________________________________________________________________ b. Project/Construction Managers ______________________________________________________ c. Total Number Licensed Design Professionals (Engineers & Architects) _______________________ d. Total Number of Field Personnel _____________________________________________________ e. Certified/Technical Personnel _______________________________________________________ f. All other (describe) ________________________________________________________________
________________________________________________________________
8. On a separate attachment, provide name of co-venturer, general description of services, project type and construction values of the 5 (five) largest joint venture projects. On a separate attachment, please provide a list of joint ventures with whom Applicant is currently working or with whom they will be working in the next year (including construction values of projects if available). 9. 10. Are your projects bonded: Yes No If “Yes”, with what company? ___________________________ Does any business enterprise wholly or partly own the Applicant? Does any business enterprise to any extent control, operate or manage the Applicant? Does the Applicant, or any of its directors, officers or employees wholly own or partially own (greater than 25%) any other business entity? Does the Applicant control, operate or manage any other business enterprise? YES NO If “Yes”, please provide details on separate attachment. Please indicate Applicant’s association(s) or society(ies) memberships (AGC, AIA, etc.)
11.
12.
Attach current financials. a. Has Applicant or any predecessor or subsidiary firm ever filed for or been in receivership or bankruptcy under Chapter 7 or 11? Yes No If “Yes”, please provide details on a separate attachment.
13.
Indicate the applicant’s Contract Revenues received during the past fiscal year and projected for the next fiscal year. CONTRACT REVENUES Previous Year Current Year a. Design/Build (Responsible for design as well as construction
In-house design Subcontracted design Total Design b. General Construction/Contracting Only (No design responsibility) c.
$____________ $____________ $____________ $____________
$_____________ $_____________ $_____________ $_____________
Construction Management i) Agency/Owner/s Rep. $______________ (No design or construction) ii) At Risk/Turnkey $______________ (Hold construction and/or design contracts)
$______________
$_____________ $_____________
$_____________
TOTAL CONTRACT REVENUES
14.
Of the Design services indicated in #13a. above, please indicate the percentage of revenues derived from each discipline: % - In House Architecture Civil Engineering Structural Engineering Design of waste water/sewer systems Soil/Geotech/Foundation Engineering Mechanical/HVAC Engineering Electrical Engineering Process Engineering Environmental Consulting Asbestos Abatement Design Land Surveying Feasibility Studies Other % % % % % % % % % % % % % % Sub-Contracted
15.
Of the General Construction activities indicated in #13 b. above, indicate what percentage are involved in the following: categories: % - In House Drilling Demolition/Dismantling/Excavation HVAC/Mechanical Industrial Cleaners/Pipeline Constr. Oil Lease % % % % % % Sub-Contracted
16.
Identify the approximate percentages of contract revenues performed for the following categories of clients for the most recent calendar year. a. Federal Government or any agency ____________% b. State, county or local government ____________% c. Real estate developers ____________% d. Private or public held corporation ____________% e. Other ____________% Detail general radius of foreign operations (i.e. Country(s)) where operations normally occur. Indicate percentage relative to total projected sales under question 12.
17.
18.
Is Applicant or any subsidiary, predecessor or other organization related to Applicant engaged in: a. Real estate development or other speculative construction. YES NO If yes, what percentage of the total contract revenues is earned from these projects _________%. The manufacture, sale or distribution of any product or process or patented production process. YES NO If yes, please provide details on an attached sheet. Has the Applicant ever held or does it now hold a franchise from a metal building manufacturer? YES NO If yes, please provide details on an attached sheet. Has the Applicant ever held or does it now hold a patent for any product or process? YES NO If yes, please provide details on an attached sheet.
b.
c.
d.
19.
Indicate the appropriate percentage of total revenues for the past 12 months by project type: % % % % % % % % % % % % % % % Office Buildings Parking Structures Pipelines Refineries/Petrochemical Religious Residential Construction Roads/Highway Schools/Colleges Shopping Centers/Retail Sports/Convention Centers Storm Water Systems Tunnels Utilities Warehouses Wastewater Systems/Treatment Plants % % % % % % % % % % % % % % %
Airports Bridges Apartments/Condominiums Dams Feasibility Studies Harbors/Piers/Ports Hospitals/Healthcare Hotels/Motels Interior Retrofit Jails/Justice Landfills Landscape Manufacturing/Industrial Mass Transit Material Handling Systems 20. 21. 22.
Are updated certificates of insurance from subcontractors kept on file? Are these certificates required to show pollution liability insurance?
YES YES NO
NO
What are the minimum limits of liability you require for your subcontractors? General Liability _________________________________ Pollution Liability ________________________________ Professional Liability _____________________________
23.
Do you require subcontractor’s policies to name you as an additional insured?
YES
NO
% Yes _______
24.
Do your contracts with subcontractors contain an indemnification provision? If yes, attach copies of all insurance requirements and indemnification clauses.
YES
NO
% Yes _______
25.
Does your company enter into written contracts where you assume liability? If yes, attach copies of all insurance requirements and indemnification clauses.
YES
NO
% Yes _______
26.
Please list your current insurance coverage information. Coverage Professional Liability General Liability Worker’s Comp. Umbrella Auto Liability Carrier Limits Expiration SIR Retrodate, if any
27.
Have any professional liability claims been made or legal action been brought in the past ten (10) years against the Applicant, its predecessor(s) or any past or present principal, partner, officer, director or employee? YES NO If yes, provide the following information for each claim on a separate sheet: a. Date of Claim/Policy Year b. Claimant or plaintiff c. Allegations d. Demand or Amount of Claim e. Insurance company response if any f. Defense attorney’s or insurance company’s evaluation of exposure to liability g. If closed, total amount paid for indemnity and defense h. Deductible applicable
28.
Have any claims arising from the actual, alleged or threatened release of pollutants been previously made against the applicant? YES NO If yes, please provide details.
29.
Is the Applicant (after proper inquiry of each director, officer or partner of the Applicant or other prospective insured party) aware of any circumstance, incidents, situations or accidents that have occurred during the past five (5) years which may result in a claim being made against the Applicant, his predecessors in business, or in any of the present or past partners, officers or directors of the Applicant?
YES
NO
If yes, on an attached sheet, please provide details per Question 23 above and indicate if the circumstance, incident, situation or accident has been reported to the Applicant’s professional liability carriers.
THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS, AND FACTS ARE TRUE, AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF COMPANY’S QUOTATION AND COMPANY’S WRITTEN AGREEMENT TO BE BOUND IS REQUIRED TO BIND COVERAGE AND TO ISSUE A POLICY. IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND WILL BE ATTACHED TO THE POLICY. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. NOTICE TO ARKANSAS APPLICANTS: “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.” NOTICE TO COLORADO APPLICANTS: “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 AUTHORITIES.” NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: “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.” NOTICE TO FLORIDA APPLICANTS: “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 IN THE THIRD DEGREE.” NOTICE TO KENTUCKY APPLICANTS: “ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER 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.” NOTICE TO LOUISIANA APPLICANTS: "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." NOTICE TO MAINE APPLICANTS: “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 OR A DENIAL OF INSURANCE BENEFITS.” NOTICE TO NEW JERSEY APPLICANTS: “ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.” NOTICE TO NEW MEXICO APPLICANTS: “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 CIVIL FINES AND CRIMINAL PENALTIES.” NOTICE TO NEW YORK APPLICANTS: “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.” NOTICE TO OHIO APPLICANTS: “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.” NOTICE TO OKLAHOMA APPLICANTS: "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" (365:15-1-10, 36 §3613.1).
NOTICE TO PENNSYLVANIA APPLICANTS: “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.” NOTICE TO VIRGINIA APPLICANTS: “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.”
If an order is received, the application is attached to the policy so it is necessary that all questions be answered in detail.
APPLICANT _______________________________________ DATE _________________________ (signature of officer of corporation) APPLICANT _______________________________________ (print name & title) BROKER _________________________________________ DATE __________________________ (print name of firm) __________________________________________ (address of brokerage firm) __________________________________________ (contact person & telephone number) __________________________________________ (agent license number)