Phone: (972) 235-3030
Toll-Free: (866) 900-RISK

Your Specialist

Zachary Whiting, ARM
EXT 140
whiting@riskpro.us




About 15 mins to complete application.
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PLEASE BE AWARE, in order for us to provide an accurate quote, ALL QUESTIONS must be answered. If you are unsure, please answer to the best of your knowledge.

Name of Firm
Contact Name

Principal Location

City
State
Zip

Telphone
E-Mail
Website

  1. Is a principal, partner, officer or director a licensed architect, engineer or registered land surveyor?
    Yes
    No
  2. Date Firm Established
  3. Is your firm currently insured ?
    Yes
    No
  4. Current carrier?
    Expiration Date
  5. Current Limits of Liability
    Deductible
  6. Premium
    Prior Acts/Retro Active date
  7. Please provide your professional service billing information, including billings attributed to consultants.
    Second Most Recently
    Completed Fiscal Year

    A. Feasibility studies, reports, opinions, landscape architecture, land surveying, interior design & abandoned projects:
    $

    B. All other professional services billings:
    $

    C. Direct reimbursables (e.g., travel per diem, etc.):
    $

    D. Fees paid to consultants:
    $

    Total of A through D:
    $
    Most Recently
    Completed Year

    A. Feasibility studies, reports, opinions, landscape architecture, land surveying, interior design & abandoned projects:
    $

    B. All other professional services billings:
    $

    C. Direct reimbursables (e.g., travel per diem, etc.):
    $

    D. Fees paid to consultants:
    $

    Total of A through D:
    $
    Current Year
    Estimated Billings


    A. Feasibility studies, reports, opinions, landscape architecture, land surveying, interior design & abandoned projects:
    $

    B. All other professional services billings:
    $

    C. Direct reimbursables (e.g., travel per diem, etc.):
    $

    D. Fees paid to consultants:
    $

    Total of A through D:
    $


  8. Are greater than 10% of your billings attributable to any of the following: (If yes, please explain in Question 17):

    Design/Build:
    Yes
    No

    Pollution:
    Yes
    No

    Product Design:
    Yes
    No

    Asbestos Services:
    Yes
    No

  9. Are you owned by or do you own another entity which provides construction or real estate related services?
    Yes
    No
    (If yes, please provide details in Question 17)
  10. Please indicate the percentage of the following disciplines in which the Applicant is engaged: (Must Total 100%):
    % Architecture
    % Interior Design
    % Civil Engineering
    % Construction Management
    % Electrical Engineering
    % HVAC Engineering
    % Landscape Architecture
    % Land Surveying
    % Mechanical Engineering
    % Structural Engineering
    % Transportation Engineering
    % Other:
    % Other:

  11. Please indicate the percentage of billings derived from each project type: (Must Total 100%):
    % Airports
    % Apartments
    % Bridges (less than 500 ft)
    % Bridges (more than 500 ft)
    % Condominiums
    % Convention Centers
    % Correctional Facilities
    % Custom Homes
    % Educational
    % Environmental Impact Statements
    % Highways/Roads
    % Hospitals
    % Industrial
    % Mass Transit Lines
    % Municipal Water Systems
    % Office Buildings
    % Parking Garages
    % Hotels/Motels
    % Renewable Energy Power Plants (utility scale)
    % Power Plants
    % Religious
    % Sewer/Water Lines
    % Shopping Centers
    % Site Development
    % Subdivision/Tract Housing
    % Subsidized Housing
    % Warehouses
    % Wastewater Treatment
    % Other:

  12. Percentage of gross annual billings from renewable energy services attributed to the following? (Does not need to total 100%)
    % Solar/Wind (On-shore)
    % Off-shore Wind
    % Smart Grid
    % Energy Efficiency Consulting
    % Other:

  13. Indicate the types of clients: (Must Total 100%)
    % Commercial
    % Contractors
    % Design Professionals
    % Developers
    % Governmental
    % Industrial
    % Institutional
    % Lending Institutions
    % Owners acting as builders
    % Other:

  14. In the past 10 years have any claims, suits or demands been made against the firm, its predecessor or any past or present principal?
    Yes
    No

    If yes:
    Number of claims:

    Total Paid/Incurred (incl. reserves):
  15. After inquiry, is the Applicant aware of any act, error, omission or circumstance that may possibly result in a claim being made against them?
    Yes
    No
    If yes, please explain in Question 17
  16. Risk Management
    Does your firm:
    1. Use written in-house quality control procedures?
      Yes
      No
    2. Have an automated master specification system?
      Yes
      No
    3. Have an in-house program for continuing education?
      Yes
      No
      -How many employees have least six hours
      of continuing education in the past 12 months?
    4. Use written contracts on at least 90% of your projects?
      Yes
      No
    5. Provide professional services for any client in which any
      member of the firm or their relatives own a financial
      interest or serves as an officer, director, trustee or partner?
      Yes
      No
    6. Participate in any written joint venture agreements?
      Yes
      No
    7. Use at least 70% of your consultants that are covered by
      professional liability insurance?
      Yes
      No
  17. Please explain all "Yes" answers to questions 8, 9 or 15
  18. We have total staff categorized as follows:
    Licensed Professionals
    Technical
    Office
  19. List professional society memberships:[check ALL that apply]
    AIA
    NSPE
    ACEC
    ASLA
    ASCE
    ASME
    ASID
    ASGCA
    AEE
    NABCEP Certified
    Other (please specify):
  20. HOW DID YOU HEAR ABOUT US?
    Google Adwords
    Search Engine
    Referred
    Direct Mail
    Other:


    I/We hereby declare that the above statements and declarations are true and that I/We have not suppressed or misstated any material facts. I/We agree that any misrepresentation or misstatement of material facts may void coverage under this insurance. I/We agree that this application shall be the basis of the contract with the company and that coverage, if written, will be provided on a claims made basis. It is understood and agreed that completion of this application does not bind the company to provide coverage or the applicant to purchase the insurance.

    Check here to agree to the above statement:

    Name:
    Title:
    Date:

    All information provided is confidential and will be used soley to obtain an indication for coverage. Coverage cannot be bound from this information sheet.


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