Apply below to see if you qualify 1Company Information2Business Structure3Loss History4Operations5Accounting6Staff Size7Subcontractors8Surveying Services9Projects10Clients11Loss Prevention12Applicant Information13Business Information14Prior Coverage Information15Agent Information Company Name*Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do You Have A Website?*Please SelectYesNoWebsite Contact Name* First Last Phone*FaxEmail* Applicant's Business Structure* Partnership Sole Proprietorship LLC Corporation Professional Corporation Subchapter S Corporation Other (please specify) Describe Other Business Structure*Federal Tax Id NumberPlease enter a number from 100000000 to 999999999.Year Firm Established?*Please enter a number from 1800 to 2050.Are you licensed?*Please SelectYesNoLicense Number*Number of years in business under this name?*Years of experience in surveying ?*Are ALL individuals above, or any other land surveyors who are responsible of projects for the applicant, members of ACSM, AAGS, CAGIS, GLIS, or NSPS*Please SelectYesNoMember of...* ACSM AAGS GLIS CAGIS NSPS Please indicate if ALL owners are members of any of the followingIf no, What Percentage are?*Please enter a number less than or equal to 100.Professional Qualifications*Please indicate full name and professional qualifications (if any) for all principals, partners, key personnel, directors or officers Loss HistoryPrior Losses?*Please SelectYesNo ClaimsPlease explain reason for losses* OperationsStates of operation* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Requested Limit*Please Select500,000/1,000,0001,000,000/2,000,0002,000,000/4,000,0003,000,000/6,000,0004,000,000/6,000,0005,000,000/10,000,000 Accounting Year DataEstimated gross revenue estimate for the next 12 months?*Gross revenue for the past 12 month billing period?*Provide total gross billings for two years prior to past 12 months (if any)*Provide total gross billings for three years prior to past 12 months (if any)* Staff SizeDo you allow your license to be used by others to obtain a permit without your supervision on the job site?*Please SelectNoYesNumber of Principals, Partners or Officers*Please Select12345 or More1st Principals, Partners or Officers Name* First Last 2nd Principals, Partners or Officers Name* First Last 3rd Principals, Partners or Officers Name* First Last 4th Principals, Partners or Officers Name* First Last 5 or more 1st Principals, Partners or Officers Names*Number of other registered Land Surveyors and/or Engineers?*Total number of Supervisors, Instrument Operations*How many of those are full time?*How many of those are part time?*Total number of other field personnel?*How many of those are full time?*How many of those are part time?*Total number of clerical employees?*How many of those are full time?*How many of those are part time?*Any on-staff licensed engineers?*Please SelectNoYesAny financial interest in any project which you render professional services?*Please SelectNoYes SubcontractorsDo you Utilize Sub Contractors?*Please SelectYesNoHow are subs used?*Are subs required to be insured?*Please SelectYesNoAre Certs Obtained*Please SelectYesNoPercentage of Work done by Subcontractors*Please enter a number less than or equal to 100. Surveying ServicesFor the following questions, please indicate approximate percentage the different types of work you perform (This should total 100%)Please Select All Types of Work You Preform* Boundary/Property Construction Staking Hydrographic Geographic Info Systems (GIS) Route Surveys for Engineering Projects Plans and specifications for streets or highways, natural drainage, utilities or buildings Subdivision work – grading & site work, roads, streets, curbs, gutters, drainage, utilities Mapping/Cartography Oil/Gas Well Location Photogrammetric Topographic Quantity Survey % of Boundary/Property*% of Construction Staking*% of Hydrographic*% of Geographic Info Systems (GIS)*% of Route Surveys for Engineering Projects*% of Plans and specifications for streets or highways, natural drainage, utilities or buildings*% of Subdivision work – grading & site work, roads, streets, curbs, gutters, drainage, utilities*% of Mapping/Cartography*% of Oil/Gas Well Location*% of Photogrammetric*% Topographic*Total Percentage*Your Select Areas of Work Must Equal 100%Any other work not listed above?*Please SelectNoYesPlease explain the breakdown of the other work performed*Percentage of Above Services preformed by a Sub-Contractor*Please enter a number less than or equal to 100.Percentage of Surveying preformed under a Engineering Seal*Please enter a number less than or equal to 100. ProjectsFor the following questions, please indicate approximate percentage of your total gross billings in prior 12 month term derived from each type of project below (This should total 100%)Please Select Which Projects You have worked on in the Prior 12 Months* Airport Facilities (except terminals) Hotels/Motels Petro/Chemical Airport Terminals Houses/Single Family Residential Potable Water Systems Amusement Rides Industrial Waste Treatment Real Estate Development Apartments Jails/Justice Recreation/Sports Assisted Living Facilities Landfills/Solid Waste Facilities Roads/Highways Bridges LIBRARIES Schools/Colleges Churches/Religious Manufacturing/Industrial Shopping Centers Condos/Co-ops Mass Transit Storm Water Systems Convention Centers/Arenas/Stadiums Multi-Family Residential (excl condos) Tunnels Dams Nuclear/Atomic Warehouses Dormitories Office Buildings/Banks Water/Sewer Pipelines Environmental Remediation Parking Structures Water/Wastewater Treatment Harbors/Piers/Ports Parks/Pools/Playgrounds Water/Sewer Pipelines Utilities Hospitals/Health Care % of Airport Facilities (except terminals)*% of Hotels/Motels*% of Petro/Chemical*% of Airport Terminals*% of Houses/Single Family Residential*% of Potable Water Systems*% of Amusement Rides*% of Industrial Waste Treatment*% of Real Estate Development*% of Apartments*% of Jails/Justice*% of Recreation/Sports*% of Assisted Living Facilities*% of Landfills/Solid Waste Facilities*% of Roads/Highways*% of Bridges*% of Libraries*% of Schools/Colleges*% Churches/Religious*% of Manufacturing/Industrial*% of Shopping Centers*% of Condos/Co-ops*% of Mass Transit*% of Storm Water Systems*% of Convention Centers/Arenas/Stadiums*% of Multi-Family Residential (excel condos)*% of Tunnels*% of Dams*% of Nuclear/Atomic*% of Warehouses*% of Dormitories*% of Office Buildings/Banks*% of Water/Sewer Pipelines*% of Environmental Remediation*% of Parking Structures*% of Water/Wastewater Treatment*% of Harbors/Piers/Ports*% Parks/Pools/Playgrounds*% of Utilities*% of Hospitals/Healthcare*Total Percentage of Billing's*Total Billings must Equal 100 % Are there any other areas of billing in your previous 12 month term other than the ones listed above?*Please SelectNoYesPlease list the remaining percentages and billings for projects* ClientsFor the following questions, please indicate approximate percentage of your total gross billings in prior 12 month term derived from each type of client below (This should total 100%)Select Which Type of Client Billings* Federal Government Foreign Government Financial Institutions Manufacturing/Industrial Entities State Government Commercial Entities General or Specialty Contractors Attorneys Other Design Professions Local Government Design-Build Contractors Institutional Entities (Non-Public) Lending Institutions Real Estate Developers % of Federal Government*% of Foreign Government*% of Financial Institutions*% of Manufacturing/Industrial Entities*% of State Government*% of Commercial Entities*% of General or Speciality Contractors*% of Attorneys*% of Other Design Professions*% of Local Government*% of Design-Build Contractors*% of Institutional Entities (Non-Public)*% of Lending Institutions*% of Real Estate DevelopersTotal Customer Billings*Customer Billings must equal 100% to proceed.Are there any other categories of clients not listed above?*Please SelectNoYesPlease list the remaining percentages for clients* Risk Management and Loss PreventionAre written contracts used in every project?*Please SelectYesNoDescribe how payment was obtained and agreements were made*Percentage of Written Contract*Please enter a number less than or equal to 100.Percentage of Written Contracts that contain specified terms*Please enter a number less than or equal to 100.Does Your Firm have procedures for monitoring and collecting outstanding fees?*Please SelectFee Monitored and CollectedNot Monitored or CollectedWhat percentage of your firm's projects do you engage with your client to produce a documented scope of services and accuracy standards, such as those established by ALTA/ACSM surveys, which are incorporated into the written agreement?*Please enter a number less than or equal to 100.What percentage of your firm's projects do you engage in a pre-project planning process that results in a project definition document?*Please enter a number less than or equal to 100.What percentage of your firm's instruments of service or deliverables are internally or externally peer reviewed prior to their delivery?*Please enter a number less than or equal to 100.What percentage of your projects with sub-consultants or sub-contractors do you recieve both a written agreement and insurance certificates evidencing general liability and professional liability coverage's?*Please enter a number less than or equal to 100. Business InformationDoes your firm or any subsidiary, principal, partner or officer have a percentage ownership interest or control of a company engaged in:Actual construction, fabrication or erection*Please SelectYesNoDesign, manufacture, sale, lease or distribution of any product, process or patented production process*Please SelectYesNoReal Estate Development*Please SelectYesNoGround Testing (other than percolation tests) or survey of subsurface conditions*Please SelectYesNoDoes your firm or any subsidiary, principal, partner or officer have a 49% or more percentage ownership interest or control of a company engaged in?*Please SelectYesNoDoes your firm render services on behalf of any other entity in which any principal, partner, officer, director or shareholder of your firm or an immediate family member of such person is a partner, officer, director, shareholder or employee?*Please SelectYesNoIs your firm controlled, owned by or associated with or does your firm control or own any other entity?*Please SelectYesNoHas your firm ever been party to any acquisition, consolidation, dissolution, merger, change in name or change in business organization?*Please SelectYesNoHas your firm or any subsidiary or predecessor firm ever filed for or been in receivership or bankruptcy?*Please SelectYesNo New Applicant InformationHave any claims been made or legal action been brought in the past ten years (or made earlier and still pending) against your firm, its predecessor(s) or any past or present principal, partner, officer, director, shareholder or employee?*Please SelectYesNoHow many claims?*Please Select1231st Claim Information*Date of Claim, Claimant or Plaintiff, Allegations, Demand or amount of claims, Insurance company reserve, if any, Defense Attorney's or insurance company's evaluation of exposure/potential liability, Defense and indemnity Paid to Date and status (open/closed), Deductible applicable2nd Claim Information*Date of Claim, Claimant or Plaintiff, Allegations, Demand or amount of claims, Insurance company reserve, if any, Defense Attorney's or insurance company's evaluation of exposure/potential liability, Defense and indemnity Paid to Date and status (open/closed), Deductible applicable3rd Claim Information*Date of Claim, Claimant or Plaintiff, Allegations, Demand or amount of claims, Insurance company reserve, if any, Defense Attorney's or insurance company's evaluation of exposure/potential liability, Defense and indemnity Paid to Date and status (open/closed), Deductible applicableAfter complete investigation and inquiry, do any of the principals, partners, officers, directors, members, shareholders, employees, or insurance managers have knowledge of any act, error, omission, fact, incident, situation, unresolved job dispute (including owner-contractor disputes), accident, or any other circumstance that is or could be the basis for a claim under the proposed insurance policy?*Please SelectYesNoREPORT KNOWLEDGE OF ALL SUCH INCIDENTS TO YOUR CURRENT CARRIER PRIOR TO YOUR CURRENT POLICY EXPIRATION. Do you or any subsidiary or predecessor firm have any CURRENT outstanding professional liability deductible obligations?*Please SelectYesNoOutstanding professional liability claims*What is the exact amount owed to insurance company and , if a payment schedule is in place, the amount and dates of repayments. Prior Coverage InformationHas any similar professional liability insurance been issued to the firms or persons named in this application?*Please SelectYesNoExisting Policy Types* General Liability Workers Compensation Commercial Property Commercial Auto Commercial Umbrella/Excess Inland Marine/Equipment Floater Carrier Name*Please SelectHiscoxSecond ChoiceThird ChoicePolicy NumberDeductible*Effective Date of Current Policy MM slash DD slash YYYY Expiration Date of Current Policy MM slash DD slash YYYY Current Premium*If not known please use an approximation Current General Liability Limits*Please Select$500,000/$1,000,000$1,000,000/$2,000,000Please enter any Retroactive Date MM slash DD slash YYYY Date in which you got your 1st policyEstimated Total Current Premium Agent NameAgency NameAgency AddressAgency PhoneAgency FaxAgency Email Agent Resident License NumberAgent Non-Resident NumberAgent Resident License Expiration Date MM slash DD slash YYYY Agent Non-Resident License Expiration Date MM slash DD slash YYYY
