AEE Application

Selvaggio, Teske & Associates - Risk Management Partners for the Design and Build Industry

Architects / Engineers / Environmental Consultants
(A/E/E) Application

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Ohio firms only.

This application is for professional liability insurance that is provided on a claims made basis. The policy applies to claims arising out of your professional services performed on or after any retroactive date shown in the policy, and is subject to all policy terms, conditions, declarations and endorsements.

The policy contains a provision permitting claim expenses, including legal defense costs, to be applied against the deductible. Subject to restrictions in certain states, the payment of claim expenses reduces the Limits of Insurance available to pay claims and the Company has the right to designate legal counsel and uses panel counsel, as needed, for claims covered by any insurance provided.

* Indicates required fields.

*Firm’s full name:
*Contact name
*Street address:
Mailing address:
*City, State, Zip:
*Telephone:
Facsimile:
E-mail:

Renewal clients will be required to provide following items:
Resumes of principals, partners and officers who are new to your firm within the last policy period. A list of your firms five largest projects (completed or in progress) for the last policy period, or current Standard Form 254. Please provide your firms financial statements for the last year only. If applicable any new brochures and/or resumes of principals new to the firm.
New applicants will be required to submit the following items:
Resumes of all principals, partners, and officers (KEY PERSONNEL). Financial statements for the last two years. A list of your firms 10 largest projects (completed or in progress) within the last five years, or current Standard Form 254. A copy of your firms standard contract form. If you use unmodified standard professional association forms, provide form numbers only, not copies. Brochures describing your firm’s services.
New applicants providing environmental services will be required to submit the following:

A sample copy of a preliminary site assessment.
A copy of your firms health and safety plan.
Your quality assurance or quality control manuals, or other standard operating procedures.
Your firms financial statements for the last two years.
Copies of your firms standard subconsultant and subcontractor contract forms. If you use unmodified standard professional association forms, provide form numbers only, not copies.

Date your firm was established

Entity Type:

Sole Proprietorship

Joint Venture

Partnership

Limited Liability Corp

Corporation

Limited Liability Partnership

Other (please explain below)

Have you formed any joint venture, LLC, or any "in association with" contractual relationships? Yes No

Is your Practice Full Time (more than 30 hours per week)? Yes

Is your Practice Part Time (less than 30 hours per week)? Yes

List all pre-existing entities, including acquisitions and mergers, and their dates of existence:

Entity: From: To:

Number of Personnel

Principals:		Do not include below.
Professionals:		Include registered and licensed (project managers, architects, engineers, scientists
Technical:		CAD operators, drafting, field, laboratory
Non-technical		Equipment operators and other field personnel
Administrative and other:
Personnel Total:		Indicate the no. of part time
Does your firm ever share employees with other firms or has any other firm shared employees with you? Yes No

List all professional societies and associations to which your firm and KEY PERSONNEL belong:

If you have field technicians, list certifications: (e.g., ACI, CHMM, CWI, NICET, OSHA: 40-hour, etc.

If your firm has a laboratory, list accreditations: (e.g., A2LA, AASHTO, State EPA, ISO, etc.)

Do any other entities, or individuals not employed by your firm have any ownership interest in your firm?	Yes	No
If yes, list the owners and indicate their percentage of interest in your firm.

Does your firm or any KEY PERSONNEL own any interest in any construction, erection, manufacturing, fabrication or real estate development company?	Yes	No
If yes, list the following for the last complete year: Owner: Amount of ownership: Name of entity: Relationship to your firm: Nature of Activities: Entity's GROSS RECEIPTS:

Does your firm or KEY PERSONNEL engage in actual construction, erection, manufacturing, fabrication, or real estate development? If yes, please provide details:	Yes	No

Are professional services provided by your firm to any entity in which your firm or KEY PERSONNEL maintains a cumulative ownership interest greater than ten percent (10%)?

If yes, you will be required to complete an Entity Ownership Questionnaire.

Yes

10.

Provide your firms GROSS RECEIPTS attributable to the following years. (Include all receipts for projects insured by project policies within the GROSS RECEIPTS column an list separately in the Project Policy Receipts column.)

GROSS RECEIPTS means the EXACT dollar amount of your firm's gross revenues, including subconsultants and reimbursables, but not including interest income, rental income on real estate, or sales and service taxes.

Fiscal Year End (00/00/0000)		Gross Receipts	Reimbursables	Project Policy Receipts*
	Est. current year
	Last complete year
	Two years ago
	Three years ago

* You will be required to complete a Project Insurance Questionnaire

11.

List all office locations with a contact name and the percentage of your firms GROSS RECEIPTS derived from each location for the last complete year: street address, city, state, zip, contact name.

12.

Provide the percentage of your firms GROSS RECEIPTS that were paid to subconsultants and subcontractors during the last complete year.

Not Applicable

Subconsultants	Insured for Professional Liability	Not Insured for Professional Liability
Structural engineering
Environmental services*
Other professional services

Subcontractors	Insured for Contractors Pollution Liability (CPL)	Not Insured for Contractors Pollution Liability (CPL)
Structural engineering
Environmental services*
Other Professional services
* As described within Environmental Services in question 14C

13.

Does your firm obtain the appropriate certificates of insurance?

From your subconsultants?	Yes	No
From your prime professionals?	Yes	No
From your subcontractors?	Yes	No

You may be required to provide copies.

14.

Provide the percentage of your firms GROSS RECEIPTS attributable to the following services during the last complete year.

A. Design and Other Related Services (non-environmental)

1. Design Services:

a. Total of all design services
     Percentage with construction observation
     Percentage without construction observation*
     DESIGN SERVICES SUBTOTAL (must equal 100%)

* Please describe how you ensure your design intent is being met? Or any contractual remedies you use to protect your firm.

2. Non-design services:

a. Quantity or cost estimates without design
b. Plan checking without design
c. building commissioning
                            (quality assurance process as a separate service)
d. Feasibility, programming, planning, economic or
                            seismic studies
e. Architectural master planning
f. Forensic inspections, expert witness services,
                            failure analysis

3. Field Services:

a. Construction observation without design
b. Inspection as a stand-alone service
c. Boundary and construction staking
d. Construction materials testing
(including compaction testing)

4. Laboratory analysis (including soils and construction materials,
but not environmental)

5. Other (describe)

B. Operation and Management Services (of these facilities)

1. Domestic Water, utility, building, other facilities

2. Wastewater treatment plants, landfills, chemical processing plants

(describe)

3. Other (describe)

C. Environmental Services

1. Environmental engineering (detection, determination and remediation of contaminated sites.

a. Preliminary site assessments (PSA-Phase I)
b. Other environmental assessments (compliance audits,
                               environmental impact studies)
c. Investigations (drilling and sampling, Phase II)
d. Studies (feasibility, siting, closure, hydrogeological,
                              hydrological)
e. Asbestos and lead studies (inspection, identification,
                               work plans)
f. Asbestos and lead abatement
g. Design Services (remediation, environmental facilities,
                               pollution control systems)
h. Site remediation activities and remediation observation
                              or management
i. Environmental project observation/oversight (non-
                              remediation)
                            (describe)

2. Environmental Sciences.

a. Permitting
b. Industrial hygiene
c. Laboratory analysis (chemical & analytical)
d. Environmental training and manuals
(for other than internal usage)
e. Fish and wildlife or botanical studies,
including wetland delineation
f. Forensic inspections, expert witness services

3. Other environmental services
(describe)

SERVICES TOTAL (must equal 100%)

15.

Provide the percentages, based on your firms GROSS RECEIPTS, attributable to the following disciplines provided by your firm, excluding your subconsultants.

Discipline	Estimated current year	Last complete year

ARCHITECTURE
Architectural Planning (including master planning)
Interior design and graphics
Landscape architecture
Construction Manager-advisor
Construction Manager-at risk


ENGINEERING
Structural engineering
Civil engineering
Civil wastewater engineering (municipal, non-industrial)
Land surveying
Traffic engineering
Mechanical engineering
Acoustical engineering
Process engineering
Electrical engineering
Illumination engineering
Geotechnical engineering (soil mechanics for structures)
Geotechnical field services and construction materials testing (including drilling)


LABORATORY
Construction materials testing (non-environmental)
Environmental (analytical)
Conformity assessment* (product testing and materials science)
Life sciences* (clinical research - not diagnostic medical labs)
Microbiology and analytical chemistry* (food, drugs, personal care products)


ENVIRONMENTAL
Environmental engineering (including mines and mining waste treatment) - See question 14C
Environmental science - See question 14C
Industrial wastewater engineering (non-municipal)
Geo-environmental engineering (including landfills, wastewater treatment retention ponds)


OTHER
Marine engineering (describe)
Naval architecture (describe)
Other (describe)


DISCIPLINES TOTAL (must equal 100%)

16.

Provide the percentage of your firms GROSS RECEIPTS attributable to the following projects during the last complete year.


HIGH RISE
All buildings over 15 stories (Do NOT classify these buildings below.)


RESIDENTIAL
Residential condominiums
Planned Unit Developments (PUDs)
Single-family residential subdivisions
Custom homes
Apartments


INSTITUTIONAL
Hospitals, retirement homes, convalescent hospitals
Public schools, colleges and universities
Private schools, colleges and universities
Churches
Correctional institutions


INDUSTRIAL
Processing, manufacturing production systems
Mines, quarries, tunnels
Oil refineries
Chemical plants and pipelines
Facilities related to nuclear activities


GENERAL BUILDING
Parking garages
Hotels
Motels
Retail, malls, shopping centers
Office, warehouse, processing, manufacturing and production buildings
Restaurants


RECREATION FACILITIES
Sport facilities, arenas, convention facilities, grandstands, theaters, amusement parks (describe your services for each)
Ski lifts


INFRASTRUCTURE
Utilities
Roads and highways
Airport/airport runways
Transportation passenger terminals (describe services)
Structures for offshore or marine use, harbors, jetties, docks, piers wharves
Bridges, trestles
Dams, reservoirs, levees
Landfills
Wastewater, sewage and water treatment systems
Waste treatment, storage or disposal facilities


OTHER
All other environmental projects (including remediation sites. e.g. National Priorities List, Superfund and UST)
Other (describe)


PROJECTS TOTAL (must equal 100%)

17.

Provide the percentage of your firms GROSS RECEIPTS attributable to the following types of clients during the last complete year.

Private Sector:
Owners
Developers
Contractors
Design professionals
Environmental consultants
Other (describe)
Public Sector
Foreign

CLIENTS TOTAL (must equal 100%)

18.

Provide the percentage of your firms GROSS RECEIPTS attributable to projects delivered in the following manner during the last complete year.


Design-Bid-Build (traditional delivery method)
Design-Build (submit Design-Build Questionnaire)
Fast Track (describe)
Turnkey (describe)
Construction management*

PROJECT DELIVERY METHOD TOTAL (must equal 100%)


* Do you perform any construction activities or hire contractors?	Yes	No
*During the last year, was your firm, or any subconsultant or subcontractor to you, responsible for construction means, methods, techniques procedures, or job site safety?	Yes	No

If yes to either question above, explain and provide details about your firms GROSS RECEIPTS attributable to these services and a copy of the contract. If you use unmodified standard professional association forms, provide form numbers.

19.

Does your firm wish to report (or reinstate) any permanently abandoned projects that were originally intended for construction and where design receipts were generated this year or within the last three years? (Do NOT include master planning projects, feasibility studies or inspections.)

If yes, you will be required to complete an Abandoned Projects Questionnaire, if not previously submitted to us.

Yes

20.

Quality Control


a.	Does your firm utilize a written quality control manual? If yes, Please provide a copy of the Table of Contents.	Yes	No
b.	What are your procedures for reviewing all client and sub consultant contracts before they are signed?
c.	Who is the authorized signature on contracts?
d.	Have you formed any Joint Venture, Limited Liability Companies, "In association with.." or "Contractual Relationships"?	Yes	No
e.	You may need to provide a copy of your pre-project evaluation checklist.
f.	You may need to provide a copy of your post-evaluation checklist.
g.	Do you use specification/design checklists as well as procedures for their review?	Yes	No
h.	Do you utilize Masterspec or another specification software program?	Yes	No
i.	Do you use procedural or technical manuals for both in-house and field personnel?	Yes	No
j.	Does a principal check all plans before they are sent to field?	Yes	No
k.	Do you offer continuing education and training programs for professional and technical personnel?	Yes	No
	If appropriate, please explain your in-house education program:
l.	What is the percentage of professionals participating in continuing education?
m.	What states is your firm or its professionals licensed in?
n.	Do you share employees with other firms or has any other firm shared employees with you?	Yes	No
o.	What is your average employee turnover? less than 5 years 5-10 years 10+ years 20+ years
p.	What percentage of your firm's revenues is derived from repeat clients?
q.	What percentage of your firm's revenues was derived from your largest client?
r.	Did you decline work last year?	Yes	No
	If so please explain why.
s.	How many days are your accounts receivable running? 30-45 45-60 60-75 75+
t.	Have you filed suits for collection of fees during the last 2 years?	Yes	No
u.	Has the firm made adjustments or goodwill payments in any disputes involving it's services?	Yes	No
	If yes, please explain.
v.	Are you ISO certified?	Yes	No
w.	Have you ever participated in an organizational or technical peer review through a professional association?	Yes	No
	If yes, when and by whom?
x.	What steps are you taking to minimize exposure as it relates to mold?
y.	Are you advising clients of mold risks?	Yes