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1. Firm Name (please include any DBA names):
________________________________________________________________________________________________
Address: ________________________________________________________________________________________ CitStreet y State Zip
Phone:_______________________ Mobile:__________________________ Email: ____________________________
Are there any additional locations? Yes No Website: www. ________________________________
2. Who owns the firm listed in question 1? Please list the full name of each owner and show the percentage of ownership (total should equal 100%):
__________________________________ _______ % __________________________________ _______%
__________________________________ _______ % __________________________________ _______%
3. Previous entities of which any owner of the firm was a principal:
________________________________________________________________________________________________
________________________________________________________________________________________________
Year earliest entity (in question 1 or 3) was formed: ________
4. Brief description of practice: _____________________________________________________________________
________________________________________________________________________________________________
5. Types of Services (must total 100%): ____% Architecture ____% Structural Engineering ____% Civil Engineering ____% HVAC Engineering ____% Construction Management ____% Environmental Consultant ____% MEP ____% Interior Design (selection of furniture, ____% Surveying fixtures, finishes and space planning)
____% Other
6. Types of Projects (must total 100%): ____% Single Family Residential ____% Schools/Colleges/Universities ____% Commercial ____% Religious ____% Condominiums Office Buildings ____% Retail ____% Apartments ____% Industrial ____% Other _________________ ____% Hospitals _________________
____%
MALONEY & COMPANY, LLCTHE ART OF RISK MANAGEMENT
Professional Liability ApplicationFor Architects, Engineers, Surveyors and Consulting Firms
MCO20192
7. Types of Clients (must total 100%): ____% Contractors ____% Developers ____% Private Owners ____% Public Institutions ____% Design Professionals Other
____%
__________________________________
__________________________________
8. Staffing:
Licensed Architects_____ Licensed Engineers_____ Surveyors_____ Technical_____ Admin_____
9. Gross Billings:
2016: ________________________ 2015: ________________________ 2014: ________________________
Estimated Full Year Billings in 2017:
Percentage of billings attributed to low risk services (Feasibility Studies, Master Plans, Reports, andOpinions, etc.) ________ %
Does your firm perform any high risk services (e.g. Geotechnical, Asbestos, Underground Storage Tanks, andLead Abatement)? Yes No
If yes, please describe ___________________________________________________________________
__________________________________________________
_____________________________________________________________________________________
Direct reimbursable expenses included in the billings shown above (e.g. Travel, Blueprinting, and FilingFees, etc.) ________ %
10. Risk Management:
a. What percentage of your firm’s contracts are written?
________%
b. What percentage of written contracts are AIA, ConsensusDoc or EJCDC?
________%
If yes, what percentage of your contracts contain a limitation of liability clauseless than or equal to $250,000? ________%
e. Does your firm have in-house quality control procedures? ________
11. Do you have a professional liability policy in force?
Yes
No
If yes, please provide us with:
a. Name of Insurance Company
b. Limits of Liability & Deductible
c. Effective Dates
d. Retroactive Date
e. Premium
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Are you a named insured on a policy dedicated to one specific project? Yes No
Do you have a specific project excess endorsement on your current policy? Yes No
Have you ever had a professional liability policy cancelled or non-renewed? Yes No
If yes please explain: ______________________________________________________________________________
________________________________________________________________________________________________
2MCO2017
3
________________________________________________________________________________________________
c. Does your firm incorporate a limitation of liability clause in its contracts? ________
What percentage of your fees is paid to subconsultants? ________%
What percentage of your subconsultants maintain professional liability insurance? ________%
d. Does your firm retain subconsultants? ________
1. Firm Name (please include any DBA names):
________________________________________________________________________________________________
Address: ________________________________________________________________________________________ CitStreet y State Zip
Phone:_______________________ Mobile:__________________________ Email: ____________________________
Are there any additional locations? Yes No Website: www. ________________________________
2. Who owns the firm listed in question 1? Please list the full name of each owner and show the percentage of ownership (total should equal 100%):
__________________________________ % _______ __________________________________ % _______
__________________________________ % _______ __________________________________ % _______
3. Previous entities of which any owner of the firm was a principal:
________________________________________________________________________________________________
________________________________________________________________________________________________
Year earliest entity (in question 1 or 3) was formed: ________
4. Brief description of practice: _____________________________________________________________________
________________________________________________________________________________________________
5. Types of Services (must total 100%): ____% Architecture ____% Structural Engineering ____% Civil Engineering ____% HVAC Engineering ____% Construction Management ____% Environmental Consultant ____% MEP ____% Interior Design (selection of furniture, ____% Surveying fixtures, finishes and space planning)
____% Other
6. Types of Projects (must total 100%): ____% Single Family Residential ____% Schools/Colleges/Universities ____% Commercial ____% Religious ____% Condominiums Office Buildings ____% Retail ____% Apartments ____% Industrial ____% Other _________________ ____% Hospitals _________________
____%
MALONEY & COMPANY, LLCTHE ART OF RISK MANAGEMENT
Professional Liability ApplicationFor Architects, Engineers, Surveyors and Consulting Firms
MCO2017
2
7. Types of Clients (must total 100%): ____% Contractors ____% Developers ____% Private Owners ____% Public Institutions ____% Design Professionals Other
____%
__________________________________
__________________________________
8. Staffing:
Licensed Architects_____ Licensed Engineers_____ Surveyors_____ Technical_____ Admin_____
9. Gross Billings:
2018: ________________________ 2017: ________________________ 2016: ________________________
Estimated Full Year Billings in 2019:
Percentage of billings attributed to low risk services (Feasibility Studies, Master Plans, Reports, andOpinions, etc.) ________ %
Does your firm perform any high risk services (e.g. Geotechnical, Asbestos, Underground Storage Tanks, andLead Abatement)? Yes No
If yes, please describe ___________________________________________________________________
__________________________________________________
_____________________________________________________________________________________
Direct reimbursable expenses included in the billings shown above (e.g. Travel, Blueprinting, and FilingFees, etc.) ________ %
10. Risk Management:
a. What percentage of your firm’s contracts are written?
________%
b. What percentage of written contracts are AIA, ConsensusDoc or EJCDC?
________%
If yes, what percentage of your contracts contain a limitation of liability clauseless than or equal to $250,000? ________%
e. Does your firm have in-house quality control procedures? ________
11. Do you have a professional liability policy in force?
Yes
No
If yes, please provide us with:
a. Name of Insurance Company
b. Limits of Liability & Deductible
c. Effective Dates
d. Retroactive Date
e. Premium
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Are you a named insured on a policy dedicated to one specific project? Yes No
Do you have a specific project excess endorsement on your current policy? Yes No
Have you ever had a professional liability policy cancelled or non-renewed? Yes No
If yes please explain: ______________________________________________________________________________
________________________________________________________________________________________________
2MCO2019
3
________________________________________________________________________________________________
c. Does your firm incorporate a limitation of liability clause in its contracts? ________
What percentage of your fees is paid to subconsultants? ________%
What percentage of your subconsultants maintain professional liability insurance? ________%
d. Does your firm retain subconsultants? ________
12. Claims Information: a. Have any claims been made or legal action been brought in the p
director, shareholder or employee? Yes No If yes, please provide the following information for each claim on a separate sheet:
a. Date of Claim e. Deductible applicable b. Claimant or Plaintiff f. Amount paid for indemnity (if closed) c. Allegations g. Insurance company reserve mialc fo tnuomA .h ecnarusni ro s’yenrotta esnefeD .d
company’s evaluation of exposure/potential liability
b. Are you aware of any circumstances that may give rise to a claim? Yes No
If yes, please provide the following information for each circumstance on a separate sheet:
a. Date reported to Insurer d. Claimant b. Name of project e. Allegation/nature of situation c. Date of incident f. Demand/amount of damages (if known)
3
Authorization and Signature
The undersigned authorized representative of the firm, or individual if this application is for an individual, agrees to all of the following: • ehT statements and representations made in this application are true and complete and will be deemed material to
the acceptance of the risk assumed by the insurance company in the event an insurance policy is issued. • ehT insurance companies are authorized to make an investigation and inquiry in connection with this application. • ehT insurance companies are not bound or obligated to issue any insurance policy or to provide the insurance
requested in this application.
Please Note: This information is collected to request premium indications. Any insurer that offers you a policy is likely to require that its application be completed before binding coverage for your firm.
Principal Name (please print)
Principal Signature Date
After completing the form, please return it to us. It can be sent to:
Fax(800) 720-5349
Mailing Address Maloney & Company, LLC
1110 Boston Post RoadGuilford, CT 06437
MCO20194
Contact us today and let our friendly,responsive staff go to work for you.
We have access to over twenty insurancecompanies competing for your policy.
MALONEY & COMPANY, LLCTHE ART OF RISK MANAGEMENT
Maloney & Company, LLC provides state-of-the-art risk management and insurance brokerageservices to architects, engineers, surveyors and consultants. With over 650 clients, we have theknowledge and insurance company relationships to help any size design firm.
We also provide services including:
• Same Day Certificates of Insurance
• Free Contract Review
• Risk Management Materials
Typically we help clients with:
• Professional Liability Policies • Business Owners Policies • Workers’ Compensation Policies• Cyber, Crime & EPLI Policies
In Connecticut:203-458-4000
203-458-4001 fax212-333-4400
800-720-5349 fax
Toll Free:800-585-6881
800-720-5349 fax
www.MaloneyLLC.com • 1110 Boston Post Road, Guilford, CT • [email protected]
Renderings by Ruggieri & Partners, PC
MICHAEL J. MALONEY
Founder and Principal, Maloney & Company, LLC
Mike has worked in the insurance field since 1986 both for insurancecompanies and brokers and has specialized in construction-related firms since1992. He has a liberal arts degree from Colgate University and anMBA from NYU, and brings a strong business background to his work.
SANTINA RAGONESEAccount Manager, Maloney & Company, LLCSantina has worked in the finance industry since 2002 and has been licensed for insurance since 2007. She has been an Account Manager with Maloney & Company, LLC since 2012.
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