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After Completing the Form
11. Claims Information: a. Have any claims been made or legal action been brought in the past five years (or made earlier and
are still pending) against your firm, its predecessor(s) or any past or present principal, partner, officer, 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 d. Defense attorney’s or insurance h. Amount of claim
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 claim 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 the fol-lowing: •Thestatementsandrepresentationsmadeinthisapplicationaretrueandcompleteandwillbedeemedmaterialto
theacceptanceoftheriskassumedbytheinsurancecompanyintheeventaninsurancepolicyisissued. •Theinsurancecompaniesareauthorizedtomakeaninvestigationandinquiryinconnectionwiththisapplication. •Theinsurancecompaniesarenotboundorobligatedtoissueanyinsurancepolicyortoprovidetheinsurance
requestedinthisapplication.
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
MCO20124
Contact us today and let our friendly,responsive service staff
go to work for you.
Protect your firmwith the help of Maloney & Company, LLC.
Maloney & Company, LLC1110 Boston Post Road • Guilford, CT 06437
Maloney & Company, LLC provides state-of-the-art risk management and insurance brokerage services to architects, engineers and surveyors from Massachusetts to Delaware.
With over 450 clients, we have the knowledge and insurance company relationships to help any size design firm.
We also offer services such as: • 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
In Connecticut:203-458-4000
203-458-4001 fax
In New York:212-333-4400
212-333-4455 fax
In Rhode Island:401-333-3900
800-720-5349 fax
In Massachusetts:508-222-2200
800-720-5349 fax
Toll Free:800-585-6881
800-720-5349 fax
www.MaloneyLLC.com • Contact: Michael J. Maloney • [email protected]
Renderings by Ruggieri & Partners, PC
ELI HARVEYAccount Executive, Maloney & Company, LLCEli has worked in the financial services field since 2005. Prior to this he had attended LeMoyne College in Syracuse, NY and graduated with degrees in business and political science.
MICHAEL J. MALONEYFounder and Principal, Maloney & Company, LLC.Mike has worked in the insurance field since 1986 both for insurance companies and brokers and has specialized in construction-related firms since 1992. He brings a liberal arts degree from Colgate University as well as an MBA from NYU and strong business background to his work.
1. Firm Name (please include any DBA names):
________________________________________________________________________________________________
Address: ________________________________________________________________________________________ Street City 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. Type 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
Phone: (800) 585-6881 Fax: (800) 720-5349
www.MaloneyLLC.com [email protected]
Professional Liability ApplicationFor Architects, Engineers, Surveyors and Other Design Firms
MCO20132
7. Staffing: Licensed Architects_____ Licensed Engineers_____ Surveyors_____ Technical_____ Admin_____
8. Gross Billings: 2011: ________________________ 2010: ________________________ 2009: ________________________
Estimated billings in 2012: __________________________________
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.) ________ %
9. Risk Management:
a. How many employees had 6 or more hours of Continuing Education in thepast 12 months? ________
b. What percentage of your firm’s contracts are written? ________%
c. What percentage of your firm’s contracts are verbal? ________%
d. What percentage of written contracts are AIA, ConsensusDoc or EJCDC? ________%
e. Does your firm retain sub consultants? ________
Percentage of your fees paid to subconsultants ________%
f. Does your firm have in-house quality control procedures? ________
g. Are plans reviewed before being released? ________
10. Do you have a professional liability policy in force? Yes No If yes, please provide us with:
a. Name of Insurer _________________________________________________
b. Limit 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: ______________________________________________________________________________
________________________________________________________________________________________________
2MCO2012
3
1. Firm Name (please include any DBA names):
________________________________________________________________________________________________
Address: ________________________________________________________________________________________ Street City 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. Type 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
Phone: (800) 585-6881 Fax: (800) 720-5349
www.MaloneyLLC.com [email protected]
Professional Liability ApplicationFor Architects, Engineers, Surveyors and Other Design Firms
MCO20122
7. Staffing: Licensed Architects_____ Licensed Engineers_____ Surveyors_____ Technical_____ Admin_____
8. Gross Billings: 2012: ________________________ 2011: ________________________ 2010: ________________________
Estimated billings in 2013: __________________________________
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.) ________ %
9. Risk Management:
a. How many employees had 6 or more hours of Continuing Education in thepast 12 months? ________
b. What percentage of your firm’s contracts are written? ________%
c. What percentage of your firm’s contracts are verbal? ________%
d. What percentage of written contracts are AIA, ConsensusDoc or EJCDC? ________%
e. Does your firm retain sub consultants? ________
Percentage of your fees paid to subconsultants ________%
f. Does your firm have in-house quality control procedures? ________
g. Are plans reviewed before being released? ________
10. Do you have a professional liability policy in force? Yes No If yes, please provide us with:
a. Name of Insurer _________________________________________________
b. Limit 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: ______________________________________________________________________________
________________________________________________________________________________________________
2MCO2013
3
After Completing the Form
11. Claims Information: a. Have any claims been made or legal action been brought in the past five years (or made earlier and
are still pending) against your firm, its predecessor(s) or any past or present principal, partner, officer, 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 d. Defense attorney’s or insurance h. Amount of claim
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 claim 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 the fol-lowing: •Thestatementsandrepresentationsmadeinthisapplicationaretrueandcompleteandwillbedeemedmaterialto
theacceptanceoftheriskassumedbytheinsurancecompanyintheeventaninsurancepolicyisissued. •Theinsurancecompaniesareauthorizedtomakeaninvestigationandinquiryinconnectionwiththisapplication. •Theinsurancecompaniesarenotboundorobligatedtoissueanyinsurancepolicyortoprovidetheinsurance
requestedinthisapplication.
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
MCO2013 web4
Contact us today and let our friendly,responsive service staff
go to work for you.
Protect your firmwith the help of Maloney & Company, LLC.
Maloney & Company, LLC1110 Boston Post Road • Guilford, CT 06437
Maloney & Company, LLC provides state-of-the-art risk management and insurance brokerage services to architects, engineers and surveyors from Massachusetts to Delaware.
With over 450 clients, we have the knowledge and insurance company relationships to help any size design firm.
We also offer services such as: • 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
In Connecticut:203-458-4000
203-458-4001 fax
In New York:212-333-4400
212-333-4455 fax
In Rhode Island:401-333-3900
800-720-5349 fax
In Massachusetts:508-222-2200
800-720-5349 fax
Toll Free:800-585-6881
800-720-5349 fax
www.MaloneyLLC.com • Contact: Michael J. Maloney • [email protected]
Renderings by Ruggieri & Partners, PC
ELI HARVEYAccount Executive, Maloney & Company, LLCEli has worked in the financial services field since 2005. Prior to this he had attended LeMoyne College in Syracuse, NY and graduated with degrees in business and political science.
MICHAEL J. MALONEYFounder and Principal, Maloney & Company, LLC.Mike has worked in the insurance field since 1986 both for insurance companies and brokers and has specialized in construction-related firms since 1992. He brings a liberal arts degree from Colgate University as well as an MBA from NYU and strong business background to his work.
