• SURVEYOR ERRORS & OMISSIONS POLICY

    Application 20240501
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  • GENERAL INFORMATION

    If you don't have your renewal application, please proceed with filling out the rest of the application.

  • Date Established
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Firm is:

  • PERSONNEL INFORMATION

  • Specify Number of Professional Personnel Per Category
    Rows

  • GROSS RECEIPTS

    Gross receipts to include reimbursable expenses and fees paid to subconsultants:

  • Current Fiscal Year Ends:
     - -
    2 digit month, 2 digit day, 4 digit year
  • History
    Rows

  • PROFESSIONAL DISCIPLINES

  • Specify as a percentage of the firm's gross receipts, total should equal 100%:
    Rows

  • SERVICES

  • Enter the percentages of the firm's gross receipts attributable to the following categories last fiscal year:
    Rows

  • CLIENTS

  • Enter the percentages of the firm's clients based upon the following professions/sectors:
    Rows

  • PROJECTS

  • Enter the percentages of the firm's projects based upon the following categories:
    Rows
  • Please list your 5 largest revenue projects in the last 5 years
    Rows

  • CONTRACTS

  • Enter the percentages of the firm's contracts based upon the categories below:
    Rows

  • FINANCIAL AND OTHER INTERESTS

    Please answer the following questions regarding you, your firm, or any principals participating in these activities during the past 12 months.

  • Are you involved in a construction or real estate development company, engaged in any actual construction, or hired a construction contractor to perform construction work?
  • Derived more than 50% of last fiscal year's gross receipts from any one client?
  • Are involved in the manufacture of fabrication of any component, device, or system?
  • Have been the subject of disciplinary action by authorities as a result of their professional activities?
  • Have any financial interest in any projects for which it has provided professional services?
  • Is coverage for Equity Interest desired?

  • SUBCONTRACTORS / SUBCONSULTANTS

    Please provide, as a percentage of the Total Gross Receipts reported in GROSS RECEIPTS section, the fees paid to the firm's subconsultants in the following disciplines:

  •  Total Should Not Equal 100%
    Rows
  • Are all subcontractors and subconsultants hired under a written contract?
  • Does the firm obtain certificates of insurance from all subcontractors and subconsultants?

  • QUALITY ASSURANCE / CONTROL ISSUES

  • Does the firm have a written Quality Assurance / Quality Control Program?
  • Does the principal check all surveys/plans before they are sent to the field/client?
  • Does the firm have an in-house program of continuing education for professional employees?
  • Has the firm participated in an Organizational Peer Review in the past 5 years?

  • CLAIMS / LIABILITY ISSUES

  • Have any E&O/Professional Liability claims been made against the firm or any of its members?
  • Does the firm or any of its members have any knowledge of prior acts, errors, omissions, or unresolved job controversy or other matter or circumstance which might reasonably be expected to give rise to a claim under this insurance?
  • Does the firm have any pending dispute concerning the payment of fees to the firm for service rendered?
  • Has the firm or any of its members given notice to any other E&O/Professional Liability underwriter of any actual or alleged act, error, omission, deficiency, property damage, or bodily injury, circumstance, incident, situation, accident, unresolved job controversy or fee disput which could result in a claim?

  • LIMITS AND DEDUCTIBLES

    The firm would like a quotation based on the following limits and deductibles:

  • Limit(s):
  • Deductible(s):

  • INSURANCE HISTORY

  • Has any insurer cancelled or refused to renew any similar insurance issued to the firm or any of its members?
  • Please detail Professional Liability insurance for the past 3 years. Show current policy and prior 2 years.
    Rows
  • Retroactive Date on Current Policy
     / /
    2 digit month, 2 digit day, 4 digit year

  • Please provide current General Liability policy information:

  • Information To Be Submitted

    The following information may be requested prior to binding:

    • Claims history/loss summary for the past five years.
    • Resumes of key licensed land surveyors/professionals on staff.
    • Copy of current policy declaration page (if any) to confirm retro date.

    Mail to ANCO Insurance, 3103 Bee Cave Road, Suite 242, Austin, Texas 78746 or Fax to (512) 330-9856.

  • SUBMISSION INFO

    Must select "agree" to the following statements to continue quotation.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Important: Please check the box below. You will need to sign (above) this application and then select "Submit" below. You will be emailed a copy of this application for your records to use as a reference for your renewal.

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