Professional Insurance Experts

head_logo_img
time_icon_img
07:00AM - 08:00PM

Monday to Friday

sprt_icon_img
Online Support 24/7

+(469)777-3025

email_icon_img
Email Us

[email protected]

Menu
REQUEST QUOTE
MAKE A PAYMENT

Application for Design and DataTM Insure Liability Coverage

NOTICE

Notice: The insurance coverage for which you are applying is written on a Claims Made and Reported policy. Only claims that are first made against you during the policy year and reported to us within that policy year, or within 60 days after the end of the policy year, are covered, subject to policy provisions. The limits of liability available to pay damages, including judgment or settlement amounts, shall be reduced by amounts incurred for claims expenses. Further note that amounts incurred for claims expenses and damages shall also be applied against the deductible amount.

"*" indicates required fields

1. APPLICANT INFORMATION

Relation

DD slash MM slash YYYY
List branch office locations (if any) and the percentage of fees derived from each location
Provide the number of personnel in each of the following categories
Number employed
Number Registered/Licensed
Show the number of employees who left the firm in the past 12 months:
Drop files here or
Max. file size: 10 MB, Max. files: 5.

    2. APPLICANT INFORMATION


    Please provide the following information regarding your gross fees. Gross fees means the exact dollar amount of gross revenues from Professional Services including fees paid to subconsultants, however, excluding direct reimbursables by contract (i.e., travel, per diem, reproduction costs, etc.).

    Total Gross Fees
    Does the firm provide Professional Services on any project in which it has an equity interest?
    Please identify the approximate percentage of fees earned on projects by construction value (Must total 100%)
    Please identify the percentage of services rendered (Must total 100%)

    3. DISCIPLINE INFORMATION


    Please indicate the approximate percentage of last fiscal year gross fees in the disciplines below (Must Total 100%)

    4. SUBCONSULTANT INFORMATION


    What percentage of the firm’s total gross fees for the last fiscal year were paid to subconsultants in the following disciplines (note: should be less than 100%)
    Insured for Professional Liability
    Uninsured
    Agreements
    c. Does the firm update subcontractor certificates annually?

    5. CLIENT AND PROJECT INFORMATION

    a. Does any one contract or client represent more than 50% of the firm’s last fiscal year gross fees?
    Indicate the percentage of last fiscal year gross fees derived from each of the following types of clients(Total Must Equal 100%)
    Indicate the percentage of last fiscal year gross fees attributable to the following services. Leave blank if not applicable

    6. CONTRACT INFORMATION


    Please specify the types of contracts used by the firm in the last fiscal year.
    What percentage of your professional service agreements include a Limitation of Liability to $250,000 or less?
    Drop files here or
    Max. file size: 10 MB, Max. files: 5.
      Is the firm involved in any Integrated Project Delivery (IPD) or Public-Private Partnerships (P3)?

      7. SERVICES / PROJECT INFORMATION


      Indicate the percentage of last fiscal year gross fees derived from each of the following types of projects:
      Drop files here or
      Max. file size: 10 MB, Max. files: 5.
        Has the firm provided professional services for condominium projects in the last ten years?
        Does the firm perform services under a Design-Build or Fast-Track delivery method?
        Does the firm provide or take responsibility for any site safety or construction means, methods, sequences or techniques?
        Is the firm or any principal involved in real estate development or ownership?
        Has the firm become involved in the manufacture, fabrication, sale, leasing or distribution of any product, process, component, device or system?
        Has the firm designed a building, component or system which might be used on more than one project without services for site adaptation?
        Has the firm entered into a joint venture agreement with an entity that did not provide professional design services?
        Drop files here or
        Max. file size: 10 MB, Max. files: 5.

          8. RISK MANAGEMENT

          Does the firm provide any risk management or educational programs for your staff / managers?
          If ‘yes’, did at least 50% of the firm’s professionals complete a risk management or loss prevention seminar or program (in person or web-based including Liberty’s online risk management e-Learning courses) during the last fiscal year?
          Drop files here or
          Max. file size: 10 MB, Max. files: 5.
            If ‘yes’, did at least 50% of the firm’s professionals complete a RedVector online education course through the LIU Risk Management website’s RedVector Portal during the last fiscal year?
            Are your negotiated contracts reviewed by a qualified attorney before they are signed?
            Does the firm follow written quality control procedures?
            Does the firm have a written procedure in place for collecting outstanding fees?
            Does the firm employ a written client selection process?

            If you are applying for Cyber coverage, please also complete the following information in Sections 9 through 13. Otherwise, you can skip those sections and go to Section 14.



            9. PRIVACY PRACTICES

            Does the firm employ any of the following? Please check all that apply:

            10. INFORMATION SECURITY

            Does the firm employ any of the following? Please check all that apply:

            11. DATA

            What type of personally identifiable information and sensitive information does the firm (or others on your behalf) handle, process or store? Please check all that apply:
            Does the firm employ any encryption controls in the following? Please check all that apply:

            12. CONTENT AND MARKETING CONTROL

            Does the firm employ any of the following content and marketing controls? Please check all that apply:

            13. VENDOR MANAGEMENT, CLOUD & MOBILE

            Does the firm employ any of the following? Please check all that apply:
            Untitled

            14. VENDOR MANAGEMENT, CLOUD & MOBILE

            In the last five years, have any professional liability claims been made against the firm, its predecessors or any past or present principal, partner, officer, director or employee, or any entity identified in response to questions 1 and 5?
            If ‘yes’, please complete the Claims questionnaire
            Does the firm or any of the principals, partners, officers, directors or employees, or any entity identified in response to questions 1 and 5, have knowledge of any act, error, omission, unresolved job dispute, complaints, accident or any other circumstance which might reasonably be expected to give rise to a claim under this insurance?
            In the last ten years, has any disciplinary action been filed against the firm, its predecessors or any past or present principal, partner, officer, director or employee, or any entity identified in response to questions 1 and 5?
            Is the firm aware of any release, loss or disclosure of personally identifiable information in the care, custody or control of the firm?
            Has the firm, or any of its predecessors in business, subsidiaries or affiliates, or any of the principals, directors, officers, partners, professional employees or independent contractors ever been the subject of a regulatory action as a result of the handling of sensitive data, including a civil investigative demand, consent order or investigation by an Attorney General or other industry body?
            Is the firm aware of any known network intrusion or denial of service attack during the last three years?
            Has the firm reported the matters disclosed in questions 39 through 44 above to its current or former insurance carrier(s)?
            Drop files here or
            Max. file size: 10 MB, Max. files: 5.

              Any claim arising from any facts, claims, circumstance or situations required to be disclosed in response to questions 39- 44 above will be excluded from the proposed insurance.



              15. COVERAGE INFORMATION

              Is the firm currently insured for Professional Liability coverage?
              Please provide your insurance history for the past five years below:
              Does the firm currently purchase Cyber Liability coverage?
              Please provide details on your General Liability insurance:
              Does the firm purchase any business insurance from Liberty Mutual?
              Has any insurer cancelled or refused to renew any similar insurance to the firm, its members or an entity listed in questions 1 and 5 of this application?
              Drop files here or
              Max. file size: 10 MB, Max. files: 5.
                Indicate the options the Applicant would like quoted for Professional Liability coverage:

                NOTICES

                Notice to Alabama Applicants:
                Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
                Notice to Arkansas, District of Columbia, Louisiana, Oregon, Rhode Island and West Virginia 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 agencies.
                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 of the third degree.
                Notice to Kansas and 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 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 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 Maryland Applicants:
                Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully 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 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 injury, 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
                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 Tennessee, Virginia and Washington 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.
                Notice to all other state 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 all other state 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.


                THE UNDERSIGNED AUTHORIZED EMPLOYEE OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED EMPLOYEE AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE UNDERWRITER OF SUCH CHANGES, AND THE UNDERWRITER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. FOR NEW HAMPSHIRE APPLICANTS, THE FOREGOING STATEMENT IS LIMITED TO THE BEST OF THE UNDERSIGNED’S KNOWLEDGE, AFTER REASONABLE INQUIRY. IN MAINE, THE UNDERWRITERS MAY MODIFY BUT MAY NOT WITHDRAW ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE

                NOTHING CONTAINED HEREIN OR INCORPORATED HEREIN BY REFERENCE SHALL CONSTITUTE NOTICE OF A CLAIM OR POTENTIAL CLAIM SO AS TO TRIGGER COVERAGE UNDER ANY CONTRACT OF INSURANCE.

                SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE UNDERWRITER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BECOME PART OF THE POLICY.

                ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF. FOR NORTH CAROLINA, UTAH, AND WISCONSIN APPLICANTS, SUCH APPLICATION MATERIALS ARE PART OF THE POLICY, IF ISSUED, ONLY IF ATTACHED AT ISSUANCE

                DD slash MM slash YYYY
                Scroll to Top
                foot_logo_img
                Menu
                REQUEST QUOTE
                MAKE A PAYMENT
                time_icon_img
                07:00AM - 08:00PM

                Monday to Friday

                sprt_icon_img
                Online SUpport 24/7

                +(469)777-3025

                email_icon_img
                Email Us

                [email protected]