Professional Liability (E&O) Application for Architects and Engineers

Professional Liability (E&O) Application for Architects and Engineers

Please complete the application below. To speak with a licensed agent please call 877-831-9462
Business Name *

Contact Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number*
Do you consent to receive text messages regarding your inquiry?

YesNo
E-mail*
Website
Comments/Special Requests
Is principal, partner, office or director a licensed architect, engineer or registered land surveyor*

YesNo
Year Established
Do you currently have errors and omissions insurance - if yes please complete next section*

YesNo
Please provide your professional services billing information, including billings attributable to consultants

Are greater than 10% of your billings attributable to (please check the appropriate boxes. If yes, please explain at end of application)

Are you owned by, or do you own another entity which provides construction related services? If yes, please provide details below

YesNo
If you checked yes above please provide details in this box

Please indicate the percentage of the following disciplines in which the applicant is engaged (total must be 100%)

Rows	%
Architecture
Electrical Engineering
Landscape Architecture
Civil Engineering
Full Service A/E Firm
Land Surveying
Structural Engineering
Construction Management
HVAC Engineering
Mechanical Engineering
Transportation Engineering
Other (please list and include %)

Please indicate the percentage of billings derived from each project type

In the past 10 years have any claims, suits, or demands been made against the firm, it's predecessor or any past or present principle? Number
Total Paid/Incurred (Includes Reserves):

After inquiry, is the applicant aware of any act, error, omission, or circumstance which may possibly result in a claim being made against them? Yes No
If you answered yes to the question above please provide an explanation in the box below
What percentage of your projects use written contracts
Please provide additional information below
Should be Empty: