Hiscox Insurance Company Inc.

Transcription

1 If coverage is issued, it will be on a Claims made basis. Notice: Unless the Claim Expenses outside the limit option is required to be included by the relevant state regulation or is selected by the Applicant, this insurance coverage provides that the Limit of Liability available to pay judgments or settlements shall be reduced by amounts incurred for Claim Expenses. Further note that amounts incurred for Claim Expenses shall be applied against the Retention amount. 1. Name of Applicant: Address: Website: 2. Please describe the percentages of the following services the Applicant provides or intends to provide: Last Fiscal Year Current Year Number of Licensed Staff Aerospace Engineering Architecture Chemical Engineering Civil Engineering Construction Management (Agency) Construction Management (At Risk) Electrical Engineering Environmental Engineering General Contracting HVAC Engineering Interior Designing Land Surveying Landscape Architecture Machine, Equipment, and/or Manufacturing Marine Engineering Mechanical Engineering Nuclear Engineering Process Engineering Soil Engineering Structural Engineering Other (please specify below) Page 1 of 6

2 3. Please list the state(s) in which the Applicant will be performing these services and the percentage of work in that state: State Percentage State Percentage 4. Please provide the gross billings for services listed below that were performed by the Applicant: Gross Revenues Last 12 Months Construction Values Projected 12 Months Gross Revenues Design Design/Build Actual Construction/ Fabrication/Erection Construction Management Total 5. Please provide the approximate percentages of billings derived from the following services: Construction Values a. Feasibility studies, reports, and surveys not resulting in design b. Design without supervisory services c. Design and observation d. Construction/project management e. Construction observation without design f. Inspection of existing structures g. Inspections of homes/commercial properties for prospective buyers/lenders h. Manufacture, sale, or distribution of any product or service i. Development, sale, or leasing of any computer software or hardware j. Other- please specify: 6. Based upon billings, please provide the approximate percentages of the projects below that the Applicant is engaged in: Airports Landfills Schools/Colleges Amusement rides Libraries Sewage Systems Apartments Manufacturing/ Sewage Plants Industrial Arenas/Stadiums Mass Transit Retail Structures Bridges Mines Superfund/Pollution Condos/Townhouses Municipal Buildings Telecommunications Page 2 of 6

3 Residential Commercial Convention Centers Dams Harbors/Piers Hospitals/Healthcare Hotels/Motels Industrial Waste Treatment Jails Other-please specify: Nuclear/Atomic Theaters Office Buildings Tract Homes Parking Structures Tunnels Petro/Chemical Underground Storage Tanks Pools/Playgrounds Utilities Pre-engineered Warehouses Structures Private Dwellings Wastewater Treatment Plants Recreation Water Systems Roads/Highways 7. Please include a list of the Applicant s five (5) largest jobs or projects during the past three (3) years and provide the requested details: Project/Client name Nature of the services performed for the client Revenue obtained 8. Does the Applicant follow in-house quality control procedures? Yes No Does the Applicant obtain continuing education for professional employees? Yes No How many professional employees of the Applicant have attended at least six hours of continuing education over the past 12 months? 9. Does the Applicant subcontract any professional services? Yes No If Yes, please describe/attach an explanation: 10. Limit of Liability desired: 500,000 1,000,000 2,000,000 Other 11. Retention desired: 5,000 10,000 25,000 Other Page 3 of 6

4 NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE INSURANCE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE, AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME. NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS. Page 4 of 6

5 NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365: , ). NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS MATERIALLY FALSE INFORMATION IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS. NOTICE TO VERMONT APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR, CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT ACT, WHICH MAY BE A CRIME AND MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES. Page 5 of 6

6 NOTICE TO NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. Signature of person authorized to execute on behalf of the Applicant Date The Applicant hereby acknowledges that he/she/it is aware that, unless the claim expenses outside the limit is required to be included by the relevant state regulation or is selected by the applicant, the limit of liability available to pay judgments or settlements shall be reduced, and may be completely exhausted, by claim expenses and, in such event, the company shall not be liable for claim expenses or for the amount of any judgment or settlement to the extent that such exceeds the limit of liability. The Applicant hereby further acknowledges that he/she/it is aware that claim expenses that are incurred shall be applied against the retention amount. It is understood and agreed that with respect to questions 20, 21, and 22, that if such knowledge or information exists any claim or action arising there from is excluded from this proposed coverage. I HEREBY DECLARE that, after inquiry, the above statements and particulars are true and I have not suppressed or misstated any material fact and that I agree that this application shall be the basis of the contract with the Company Signature of person authorized to execute on behalf of the Applicant Date This Application Form duly completed, together with any supplementary information, must be signed in ink or by electronic signature by the person indicated above. Signing of this form does not bind the Applicant or the Company to complete the insurance. A copy of this Application should be retained for your records. Signature of Producer Date Address of Producer Producer s License Number Page 6 of 6