• APPLICATION FOR DESIGN AND DATA INSURE™ LIABILITY COVERAGE

  • This is an application for a Claims Made and Reported policy. This application is not a binder.
  • 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.
  • 1. APPLICANT INFORMATION
  • 1. Firm Information
  • 4. List branch office locations (if any) and the percentage of fees derived from each location
  • 5. List any pre-existing or related entities and subsidiaries, their relationship or percentage of ownership, dates of existence and services provided. If coverage
    is desired for the entity, please list the retroactive date on their current professional liability coverage.
  • 6. 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:
  • 2. APPLICANT INFORMATION
  • 7. 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
  • 8. Does the firm provide Professional Services on any project in which it has an equity interest?
  • 9. Please identify the approximate percentage of fees earned on projects by construction value:
  • 10. Please identify the percentage of services rendered:
  • 3. DISCIPLINE INFORMATION
  • 11. Please indicate the approximate percentage of last fiscal year gross fees in the disciplines below:

  • Must Total 100%

  • 4. SUBCONSULTANT INFORMATION
  • 12. 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

  • 13. Agreements
  • 5. CLIENT AND PROJECT INFORMATION
  • 15. Indicate the percentage of last fiscal year gross fees derived from each of the following types of clients:

  • Total Must equal 100%

  • 16. Indicate the percentage of last fiscal year gross fees attributable to the following services. Leave blank if not applicable

  • Total Must equal 100%

  • 6. CONTRACT INFORMATION
  • 17. Please specify the types of contracts used by the firm in the last fiscal year.

  • Total Must equal 100%

  • 7. SERVICES / PROJECT INFORMATION
  • 20. Indicate the percentage of last fiscal year gross fees derived from each of the following types of projects:

  • Total Must equal 100%

  • 8. RISK MANAGEMENT
  • Please provide the date, names of the employees who completed the program, program name and provider on a separate sheet

  • 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
  • 10. INFORMATION SECURITY
  • 11. DATA
  • 12. CONTENT AND MARKETING CONTROL
  • 13. VENDOR MANAGEMENT, CLOUD & MOBILE
  • (leave blank if a Plan does not exist)
  • (leave blank if a Plan does not exist)
  • 14. CLAIMS AND CIRCUMSTANCES
  • If ‘yes’, please complete the Claims questionnaire
  • 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
  • Please provide your insurance history for the past five years below:
  • (i.e., Data Breach Liability; Media Liability; Privacy Regulatory Proceedings; Notification Costs)
  • 48. Please provide details on your General Liability insurance:
  • Drop files here or
  • 52. 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.

  • 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

  • Signature *
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