Monarch Insurance Brokers

PROFESSIONAL LIABILITY INSURANCE APPLICATION FOR ARCHITECTS AND ENGINEERS

NOTE: Completion of this application form does not bind the Insurer to offer the insurance nor does it obligate the Applicant to purchase the insurance. This application is a declaration and shall form part of any policy wich may be issued.

Do not print this page! For blank forms click here. To submit it online, complete this page and select the "Finish" button at the bottom of the page

NOTE: If the spaced provided to answer any of the questions on this application are insufficient to fully answer the question, please use the remarks section at the end of the form. If it is a continuation from a particular question, please be sure to indicate which question.

APPLICANT:

1. Name of applicant to be insured

2. Address (Head Office)

Branch Office

Date established

City

Province

Postal Code

Email

Phone Number

Fax Number

Website

Former names of applicant/firm	Date established	Closed
a)
b)

4. Is the Applicant engaged by others as an employee?
Yes
No

5. Partners and Officers (please send resume to Monarch)

Name	University Attended	Degree	Year	Province of License

6. Number of employees not including Partners and Officers:
Architects
Engineers
Technologists
Surveyors
Draftsmen
Office
Transitmen
Others

7. Please describe the nature of your practice (please send a brochure to Monarch)

8. Please list your five largest projects done during the past five years.

Name of Project	Fee	Total Construction Value	Value of your portion

9. FEES:	Previous 12 Months	Expiring 12 Months	Projected 12 Months
9. FEES:	Mo/Yr To Mo/Yr	Mo/Yr To Mo/Yr	Mo/Yr To Mo/Yr
a) GROSS FEES (include b, c, d, & e)	$	$	$
b) Fees paid to subconsultants	$	$	$
c) Fees derived from projects which have been separately insured	$	$	$
d) Fees for projects in USA	$	$	$
e) Fees for projects outside of North America	$	$	$
f) Construction Values	$	$	$

10. Please indicate percentage of fees derived from the following ENGINEERING activities (To be completed by Engineering applicants).

	% Last 12 Months	% Anticipated next 12 Months
a) Work not resulting in construction, Failures investigation	%	%
b) Structural engineering	%	%
c) Civil engineering	%	%
d) Goetechnical, surveys of subsurface conditions and ground testing	%	%
e) Mechanical engineering	%	%
f) Electrical engineering	%	%
g) H.V.A.C.	%	%
h) Project/ Construction management	%	%
i) Boundry surveys	%	%
j) Material testing & inspection services	%	%
k) Process engineering	%	%
l) Quantity survey	%	%
m) Other (describe)	%	%
Total:	100%	100%

11. Please indicate the percentage of last year's fees derived from the following areas:
a) Marine, docks and harbours %
b) Sewage and water services %
c) Roads and Highways %
d) Oil and gas pipe lines %
e) Fairground and Exhibition %
f) Bridges over 150 ft. abutment to abutment %
g) Tunnels over 150 ft. (not cut and cover) %
h) Dams %
i) Other (describe) %s

Please indicate percentage of fees derived from the following ARCHITECTURAL activities (To be completed by Architectural applicants)..

	% Last 12 Months	% Anticipated next 12 Months
a) Work not resulting in construction	%	%
b) Interior design	%	%
c) Landscape architecture	%	%
d) Private Homes	%	%
e) Apartments/Condos/Town houses	%	%
f) Commercial and office complexes	%	%
g) Industrial	%	%
h) Institutional	%	%
i) Recreational	%	%
j) Project management services	%	%
k) Other (describe)	%	%
Total:	100%	100%

13. Is the Applicant controlled by, owned by, or related to any other firm, corporation or company? If YES, please give details.
Yes
No

14. Do any of the partners or officers of the Applicant hold an interest in any other corporation with whom the Applicant carries on business? If YES, please give details.
Yes
No

15. Does the Applicant, any partner, officer or related company engage in the actual work of construction or fabrication other than supervision? If YES, please give details.
Yes
No

16. Are more than 25% of your Professional Services provided for one client? If YES, please give details.
Yes
No

17. Please list joint ventures separately insured:

18. Please provide names of all projects separately insured:

19. Please provide details of previous insurance for past five years:

INSURER	POLICY NUMBER	POLICY PERIOD		POLICY LIMIT	DEDUCTIBLE
INSURER	POLICY NUMBER	FROM	TO	POLICY LIMIT	DEDUCTIBLE
				$	$
				$	$
				$	$
				$	$
				$	$

20. a) Have any claims ever been made to the knowledge of the Applicant against the Applicant, any business predecessors, any of the present or former partners or officers?.
Yes
No

b) Is the Applicant aware of any act, error, omission or circumstance which could give rise to a claim against the Applicant or any predecessor in business, or any present or former partner or officer?
Yes
No

IF THE ANSWER TO EITHER Q. 20 a) OR Q. 20 b) IS YES, COMPLETE THE ENCLOSED CLAIMS HISTORY FORM
NOTE: THE POLICY DOES NOT COVER ANY CLAIM OR CIRCUMSTANCE STATED IN Q. 20 a) AND/OR Q. 20 b) OR ANY ERROR, ACT, OMISSION OR CIRCUMSTANCE WHICH COULD GIVE RISE TO A CLAIM, OF WHICH THE APPLICANT HAS KNOWLEDGE PRIOR TO THE INCEPTION OF THE POLICY.

21. Has any Partner, Executive Officer, Director or Professional employee had their license suspended, been fined or reprimanded during the past five years? If YES, please send the details on a separate page to Monarch.
Yes
No

22. To the Applicant's knowledge, has any company declined or terminated the insurance, for the Applicant, any present partner or officer or for any predecessor in the business, past partners or officers? If YES, please give details.
Yes
No

23. Please note the professional associations to which the Applicant belongs:

24. When is your fiscal year end?

25. Insurance Required:

LIMITS:
$250,000 / 500,000
$500,000 / 1,000,000
$1,000,000 Single Limit
$1,000,000 / 2,000,000
Other:

DEDUCTIBLE:
$2,500
$5,000
$10,000
Other:

ENVIRONMENTAL LIABILITY QUESTIONNAIRE 1. Name of Firm:

2. Please indicate the approximate percentage of total fees reported in your reported in your application for insurance (including those paid to sub-consultants but not projects insured separately) derived from each of the following project types:

	Past Accounting Year (% )	Current Accounting Year (Estimated %)
a. Studies and Reports (excluding soils investigations or remediation)
(1) Environmental impact studies or assessments	%	%
(2) Evironmental permit review or approval	%	%
(3) Building Inspections/Audits	%	%
(4) Environmental Monitoring (describe type of service)	%	%
(5) Air Emission Control Services	%	%
b. Waste Disposal
(1) Waste site evaluation or selection	%	%
(2) Design, monitoring or closure of landfills	%	%
c. Design or construction services for remedial action of contaminated buildings	%	%
d. Services related to the evaluation, removal or replacement of underground storage tanks	%	%
e. Industrial Process Engineering (Non-Petrochemical)	%	%
f. Petrochemical Engineering	%	%
g. Design of Laboratories	%	%
h. Soils Investigations
(1) Underground investigations for possible contamination	%	%
(2) Determination of extent of contamination sites	%	%
(3) Design of remedial action of contaminated sites	%	%
(4) Investigations not related to waste or contamination detection	%	%

3. How many years has your firm provided services for the detection, monitoring handling or disposal of hazardous materials?

4. Personnel (indicate the number of staff invovled in environmental work)
a. Architects/ Civil Engineers
b. Process Engineers
c. Geotechnical Engineers
d. Chemists and Biologists
e. Industrial Hygienist or Toxicologists
f. Geologists/Hydrologists
g. Environmental Engineers
h. Other Personnel
(Please send Curriculum Vitae of key personnel to Monarch if not previously submitted)

5. Have you accepted, or do you plan to accept responsibility (either directly or as an agent of the owner) for the actual clean-up, transportation, storage or disposal of a "pollutant"? If YES, please explain.
Yes
No

6. For what percentage of environmental work in the past year have you been able to obtain client agreement for:
a. Complete Indemnification
b. Partial Indemnification
c. Limitation of liability (please send sample)

7. Has any claim been made or legal action been brought for any pollution or environmental injury or damage in the past three (3) years (or made earlier and still pending) against your firm, its predecessors or employees? If YES, please provide details.
Yes
No

CLAIMS HISTORY

Only fill this out if required. Refer to Question 20 of the main section for information. If not, skip to end of application. Applicant Name:

Date:

Claim #1

Date of Loss:

Suite (Y/N):

Amount Claimed:
$

Estimated Liability:
$

Indemnity Paid:
$

Expenses Paid:
$

Closed (Y/N):

Claimant(s):

Project Name & Location:

Description of Claim:

Present Status:

Claim #2

Date of Loss:

Suite (Y/N):

Amount Claimed:
$

Estimated Liability:
$

Indemnity Paid:
$

Expenses Paid:
$

Closed (Y/N):

Claimant(s):

Project Name & Location:

Description of Claim:

Present Status:

Claim #3

Date of Loss:

Suite (Y/N):

Amount Claimed:
$

Estimated Liability:
$

Indemnity Paid:
$

Expenses Paid:
$

Closed (Y/N):

Claimant(s):

Project Name & Location:

Description of Claim:

Present Status:

REMARKS (optional - or use to complete questions above)