APPLICATION FOR DESIGN AND DATA INSURE LIABILITY COVERAGE
28 Liberty Street,5th FloorNew York, NY 10005Tel (212) 208-4100APPLICATION FOR DESIGN AND DATA INSURE LIABILITY COVERAGEThis is an application for a Claims Made policy. This application is not a binder.Notice: The insurance coverage for which you are applying is written on a Claims Made policy that applies only to Claims first made during the Policy Period or any Extended Reporting Periodand are the result of Wrongful Acts committed on or after the Retroactive Date but before the end of the Policy Period. Upon Termination of Coverage, this policy provides a sixty (60) dayAutomatic Extended Reporting Period. A Supplemental Extended Reporting Period may be purchased and is subject to the terms and conditions of this policy.No coverage exists for Claims made after the end of the Policy Period and the Automatic Extended Reporting Period unless, and to the extent, the Supplemental Extended Reporting Period applies.No coverage will exist after the expiration of the Automatic Extended Reporting Period or, if purchased, the Supplemental Extended Reporting Period, which may result in a potential coverage gapif prior acts coverage is not subsequently provided by another insurer.The Limit of Liability available to pay Damages will be reduced and may be exhausted by the payment of Claim Expenses. Once the Limit of Liability is exhausted, the Insurer shall not be liablefor Claim Expenses or Damages, settlements or judgments. Further note that amounts incurred for claims expenses and damages shall also be applied against the deductible amount.During the first several years of the Claims Made Relationship, Claims made rates are comparatively lower than occurrence rates. Substantial annual Premium increases can be expected,independent of the overall rate level increases, until the Claims Made Relationship reaches maturity.1. APPLICANT INFORMATION1. Firm InformationName of FirmContact NamePrincipal Office AddressPhone #Email AddressWebsite Address2.Sole ProprietorshipPartnershipCorporationOther3. Date the firm was established:4. List branch office locations (if any) and the percentage of fees derived from each location.City, State% Last Fiscal Year Fees5. List any pre-existing or related entities and subsidiaries, their relationship or percentage of ownership, dates of existenceand services provided. If coverage is desired for the entity, please list the retroactive date on their current professionalliability coverage.AEX-AEC-APP001-NY (07/2018)Page 1 of 12
6. Provide the number of personnel in each of the following categoriesNumber employedPrincipals, Partners, Officers & DirectorsLicensed Design ProfessionalsTechnical Personnel (including field personnel)Supervisors / SuperintendentsConstruction ManagersAll Others (describe):0Total number of employeesNumber Registered/Licensed0Show the number of employees who left the firm in the past 12 months:ManagementProfessional Staff Please attach resumes/bios for Principals, Partners and key personnel.2. FINANCIAL INFORMATION7. Please provide the following information regarding your gross fees. Gross fees means the exact dollar amount of grossrevenues from Professional Services including fees paid to subconsultants, however, excluding direct reimbursablesby contract (i.e., travel, per diem, reproduction costs, etc.).Projection for CurrentFiscal YearLast Complete FiscalYear EndingTwo Years AgoThree Years AgoTotal Gross Fees8. Does the firm provide Professional Services on any project in which it has an equity interest?If ‘yes’, please describe below:yesno9. Please identify the approximate percentage of fees earned on projects by construction value:Up to 1,000,000% 1,000,001 to 5,000,000% 5,000,001 to 25,000,000% 25,000,001 to 50,000,000% 50,000,001 to 100,000,000%Must Total 100%Over 100,000,000%10. Please identify the percentage of services rendered:US%Canada%Other%Must Total 100%If ‘other’, please describe:AEX-AEC-APP001-NY (07/2018)Page 2 of 12
3. DISCIPLINE INFORMATION11. Please indicate the approximate percentage of last fiscal year gross fees in the disciplines below:Acoustical EngineeringArchitectural PlanningArchitectureCivil – WWTPCivil EngineeringCM AgencyCM At RiskElectrical EngineeringEnvironmental EngineeringEnvironmental ScienceFire Protection EngineeringGeotechnical DrillingGeotechnical EngineeringGeotechnical Laboratory Analysis%%%%%%%%%%%%%%Illumination EngineeringInterior Design and GraphicsLaboratory Services – otherLandscape ArchitectureMarine EngineeringMechanical Engineering (HVAC)Mechanical Engineering (non-HVAC)Naval ArchitectureProcess EngineeringStructural EngineeringSurveyingTraffic EngineeringOther: describe%%%%%%%%%%%%%Must Total 100%4. SUBCONSULTANT INFORMATION12. What percentage of the firm’s total gross fees for the last fiscal year were paid to subconsultants in the followingdisciplines (note: should be less than 100%):Insured for Professional LiabilityUninsureda. Structural%%b. Environmental Services%%c. Other professional services%%13. Agreementsa. What percentage of subcontractors provide evidence of additional insured status in your favor?b. What percentage of your sub agreements include hold harmless agreements?c. Does the firm update subcontractor certificates annually?yes%%noyesno5. CLIENT AND PROJECT INFORMATION14. a. Does any one contract or client represent more than 50% of the firm’s last fiscal year gross fees?If ‘yes’, please describe below:b.What percentage of gross fees is derived from repeat clients?%15. Indicate the percentage of last fiscal year gross fees derived from each of the following types of clients:Contractors%Foreign%Design Professionals%Local Governments%Developers%Owners%Environmental Consultants%State Governments%Federal Government%Other: describe%Total Must equal 100%AEX-AEC-APP001-NY (07/2018)Page 3 of 12
16. Indicate the percentage of last fiscal year gross fees attributable to the following services. Leave blank if not applicable.Abandoned projectsAlarm or security systemsAsbestos evaluation, remediation or analysisBoundary and construction stakingBuilding commissioning servicesBuilding inspections or property condition assessmentsConceptual, schematic, or other design without construction documentsConstruction Engineering InspectionsConstruction observation/review without designConstruction materials testing (including compaction testing) and related laboratory analysisDesign with construction observation/reviewDesign without construction observation/reviewDrafting services – performed for others for a feeEnvironmental preliminary site assessments or investigations (Phase 1, PSA, drilling, sampling, Phase 2)Environmental site remediationExpert witnessFeasibility, economic, seismic or forensic studies or reportsLead evaluation, remediation or analysisLEED servicesMold evaluation, remediation or analysisOperation and maintenance servicesPermittingPlan checking without designProgram Management or other non-design related servicesQuantity or cost estimates without designRemediation design services / remediation of construction defects – non-environmentalSheeting, shoring, underpinning, scaffolding, temporary work platforms, or similarTemporary structuresTraining services – non-safety relatedTraining services – safety related%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Total Must equal 100%6. CONTRACT INFORMATION17. Please specify the types of contracts used by the firm in the last fiscal year.Client contract%Standard industry/association contract%Firm’s own standard contract%Verbal agreements%Letter of agreement%Other : describe%Purchase order forms%Total Must equal 100%18. What percentage of your professional service agreements include a Limitation of Liability to 250,000 or less?% Please submit a sample Limitation of Liability clauseAEX-AEC-APP001-NY (07/2018)Page 4 of 12
19. Is the firm involved in any Integrated Project Delivery (IPD) or Public-Private Partnerships (P3)? yesIf ‘yes’, please describe below:no7. SERVICES / PROJECT INFORMATION20. Indicate the percentage of last fiscal year gross fees derived from each of the following types of projects:Airport runwaysApartmentsBridges, trestlesBuilding envelopes, façades, glazing, curtainwallsCar dealershipsCasinos%%%%Offices, warehousesOil refineriesParking garagesParks, playgrounds%%%%%%%%Chemical plants%ChurchesColleges and universitiesCorrectional institutionsCustom homesDams, reservoirs, levees%%%%%Environmental projectsFacilities related to nuclear activitiesHarbors, docks, piers, or structures foroffshore useHigh rise – all buildings over 15 stories%%%PipelinesProcessing, manufacturing and productionbuildingsProcessing, manufacturing and productionsystemsResidential condominiumsRestaurantsRetail, malls, shopping centersRetaining wallsRetirement homes, convalescent homes, andassisted livingRoads and highwaysSingle family residential subdivisionsSki lifts, amusement rides, amusement parks%Hospitals / health care facilitiesHotelsK-12 schools- Private- PublicLandfillsMilitary facilitiesMines, quarriesMotels%%Municipal buildings%Sports facilities, arenas, convention facilities,grandstands, theatersSuperfund sitesSwimming poolsTownhomesTransportation passenger terminalsTunnelsUnderground storage tanks/gas stationsUtilitiesWaste treatment, storage or disposal facilitiesWastewater, sewage and water treatmentsystemsOther: describe%%%%%%% Please submit a Project Supplemental Questionnaire outlining the firm’s 5 largest projects21. Has the firm provided professional services for condominium projects in the last ten years?If ‘yes’, please complete the Condominium Questionnaire.AEX-AEC-APP001-NY (07/2018)%%%%%%%%%%%%%%%%%%%Total Must equal 100%yesnoPage 5 of 12
22. Does the firm perform services under a Design-Build or Fast-Track delivery method?yesnoa. If ‘yes’, what is the total percentage of your gross fees for the last fiscal year attributed to this delivery method?%23. Does the firm provide or take responsibility for any site safety or construction means, methods, sequences ortechniques?yesno24. Is the firm or any principal involved in real estate development or ownership?noyes25. Has the firm become involved in the manufacture, fabrication, sale, leasing or distribution of any product, process,nocomponent, device or system?yes26. Has the firm designed a building, component or system which might be used on more than one project without servicesnofor site adaptation?yes27. Has the firm entered into a joint venture agreement with an entity that did not provide professional design services?noyes If you’ve answered ‘yes’ to questions 22 through 27, please provide details on a separate sheet.8. RISK MANAGEMENT28. Does the firm provide any risk management or educational programs for your staff / managers?yesnoa. If ‘yes’, did at least 50% of the firm’s professionals complete a risk management or loss prevention seminar orprogram (in person or web-based including Liberty’s online risk management e-Learning courses) during the lastnofiscal year?yesPlease provide the date, names of the employees who completed the program, program name and provider ona separate sheet.b. If ‘yes’, did at least 50% of the firm’s professionals complete a RedVector online education course through the LIUnoRisk Management website’s RedVector Portal during the last fiscal year?yes29. Are your negotiated contracts reviewed by a qualified attorney before they are signed?yesno30. Does the firm follow written quality control procedures?If ‘yes’, please indicate the last date they were updated.yesno31. Does the firm have a written procedure in place for collecting outstanding fees?yesno32. Does the firm employ a written client selection process?yesnoAEX-AEC-APP001-NY (07/2018)Page 6 of 12
If you are applying for Cyber coverage, please also complete the following information inSections 9 through 13. Otherwise, you can skip those sections and go to Section 14.9. PRIVACY PRACTICESDoes the firm employ any of the following? Please check all that apply:A specific individual responsible for overall privacy and security?A written corporate privacy policy reviewed by a qualified lawyer, actively followed and regularly updated?Annual training in place for employees with respects to privacy matters?Screening of potential employees (e.g., background, drug, criminal, credit, etc.)?Regular network security assessments performed by third parties?Classification and tracking of where sensitive data is processed and stored on the network?Procedures to ensure compliance with privacy regulatory bodies, state privacy laws and industry standards, asapplicable? (e.g., HIPAA, PCI, etc.) Contracts with third parties that contain hold harmless / indemnity clauses that benefit the firm? Contracts that require third parties to carry errors and omissions or cyber insurance? Obtaining consent from individuals when collecting personally identifiable information?33. 10. INFORMATION SECURITY34. Does the firm employ any of the following? Please check all that apply:The use and application of anti-virus software on all computer devices and networks?Regular updating and patching of security systems in a timely manner?The use and application of intrusion detection and/or prevention software?The use and application of firewalls to restrict network traffic?The use and application of data loss prevention (DLP) software?Physical controls to prevent unauthorized access to company premises and network?A password policy to require strong passwords and that passwords should be updated on a regular basis?Data access controls including role based access and timely account termination?Multi-factor authentication for remote access by employees and third parties?Formal policies and procedures around the retention, destruction and purging of data?Information Technology vendors to maintain its systems and networks?11. DATA35. 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: Social Security numbers, government ID or driver license information Financial information (e.g. banking information) Payment card data Personal health information Intellectual Property Other (describe):36. Does the firm employ any encryption controls in the following? Please check all that apply: Data at rest Data in transit Mobile devices Back-up tapesAEX-AEC-APP001-NY (07/2018) Cloud StoragePage 7 of 12
12. CONTENT AND MARKETING CONTROL37. Does the firm employ any of the following content and marketing controls? Please check all that apply:Obtaining all necessary and proper rights when using content developed by third parties?Legal review of all content disseminated by the firm?Notice and Take-Down procedures in place for addressing potentially libelous or illegal content on the Company’swebsite?13. VENDOR MANAGEMENT, CLOUD & MOBILE38. Does the firm employ any of the following? Please check all that apply: Written contracts with all third parties that have access to any sensitive information? A Disaster Recovery Plan?- When was that Plan last tested?(leave blank if a Plan does not exist) A written incident response plan regarding how compromised personally identifiable information is handled?- When was that Plan last tested?(leave blank if a Plan does not exist)14. CLAIMS AND CIRCUMSTANCES39. In the last five years, have any professional liability claims been made against the firm, its predecessors or any past orpresent principal, partner, officer, director or employee, or any entity identified in response to questions 1 and 5?noyesIf ‘yes’, please complete the Claims questionnaire.40. Does the firm or any of the principals, partners, officers, directors or employees, or any entity identified in response toquestions 1 and 5, have knowledge of any act, error, omission, unresolved job dispute, complaints, accident or anynoother circumstance which might reasonably be expected to give rise to a claim under this insurance? yes41. In the last ten years, has any disciplinary action been filed against the firm, its predecessors or any past or presentprincipal, partner, officer, director or employee, or any entity identified in response to questions 1 and 5?noyes42. Is the firm aware of any release, loss or disclosure of personally identifiable information in the care, custody ornocontrol of the firm?yes43. 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 aresult of the handling of sensitive data, including a civil investigative demand, consent order or investigation by annoAttorney General or other industry body?yes44. Is the firm aware of any known network intrusion or denial of service attack during the last three years?yesno45. Has the firm reported the matters disclosed in questions 39 through 44 above to its current or former insurancenocarrier(s)?yes If you have answered ‘yes’ to questions 39-44, on a separate sheet, list details of this situation including name ofproject (if applicable), involved parties, date you became aware and description of the circumstances.AEX-AEC-APP001-NY (07/2018)Page 8 of 12
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 INFORMATION46. Is the firm currently insured for Professional Liability coverage?If ‘yes’, please provide the retroactive date on your policy:Please provide your insurance history for the past five years below:CompanyPolicy PeriodLimitDeductibleCompanyPolicy PeriodLimitnoyesnoPremium47. Does the firm currently purchase Cyber Liability coverage?(i.e., Data Breach Liability; Media Liability; Privacy Regulatory Proceedings; Notification Costs)Coverage TypeyesDeductibleRetroactiveDatePremium48. Please provide details on your General Liability insurance:Carrier:Policy Period:toPolicy Limits:Per Occurrence /49. Does the firm purchase any business insurance from Liberty Mutual?If ‘yes’, please provide details regarding line of business and policy termsAggregateyesno50. Has any insurer cancelled or refused to renew any similar insurance to the firm, its members or an entity listed innoquestions 1 and 5 of this application?yesIf ‘yes’, please provide details on a separate sheet.51. Describe any pending corporate acquisitions or historical corporate name changes or mergers and acquisitions that haveoccurred in the past 5 years:52. Indicate the options the Applicant would like quoted for Professional Liability coverage:Combined Single/Aggregate Limit////AEX-AEC-APP001-NY (07/2018)Split LimitsPer Claim/Aggregate////Per Claim DeductiblePage 9 of 12
THE UNDERSIGNED AUTHORIZED EMPLOYEE OF THE APPLICANT DECLARES THAT THESTATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED EMPLOYEEAGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THEDATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE WILL, INORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THEINSURANCE, IMMEDIATELY NOTIFY THE UNDERWRITER OF SUCH CHANGES, AND THEUNDERWRITER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS ORAUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. FOR NEW HAMPSHIREAPPLICANTS, THE FOREGOING STATEMENT IS LIMITED TO THE BEST OF THE UNDERSIGNED’SKNOWLEDGE, AFTER REASONABLE INQUIRY. IN MAINE, THE UNDERWRITERS MAY MODIFYBUT MAY NOT WITHDRAW ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS ORAGREEMENTS TO BIND THE INSURANCE.NOTHING CONTAINED HEREIN OR INCORPORATED HEREIN BY REFERENCE SHALLCONSTITUTE NOTICE OF A CLAIM OR POTENTIAL CLAIM SO AS TO TRIGGER COVERAGE UNDERANY CONTRACT OF INSURANCE. .SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE UNDERWRITER TOCOMPLETE THE INSURANCE, BUT IT IS AGR
AEX-AEC-APP001-NY (07/2018) Page 1 of 12 APPLICATION FOR DESIGN AND DATA INSURE LIABILITY COVERAGE . Fire Protection Engineering % Surveying % Geotechnical Drilling % Traffic Engineering % Geotechnical Engineering % Other: describe % Geotechnical Laboratory Analysis % 4. SUBCONSULTANT INFORMATION
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