Professional Liability (E&O) Application for Architects and Engineers

Please complete the application and submit or print and return via email, mail or fax. Contact us with any questions at the number listed above.

Contact Information:

General Information

1: Date Established:

2: Is this a full time business?

3: Is a principal, partner, officer or director a licensed architect, engineer or registered land surveyor?

4: Do you currently have errors and omissions insurance?

5: Please provide your professional services billing information, including billings attributable to consultants:

Most Recently Completed Year Second Most Recent Year Third Most Recent Year Estimated Billings for Current Year (Or First Year)
Dates of Reporting Period
Projects currently covered by project specific policies
Feasibility studies, reports, opinions, landscape architecture, land surveying, interior design and abandoned projects.
All Other Billings
Direct Reimbursables
Total Gross Billings

6: Are greater than 10% of your billings attributable to (Please check the appropriate boxes. If yes, please explain at end of application):



Product Design:

Asbestos Services:

7: Are you owned by, or do you own another entity which provides construction related services? If yes, please provide details below.

8: Please indicate the percentage of the following disciplines in which the applicant is engaged (Total must equal 100%):

9: Please indicate the percentage of billings derived from each project type:

10: In the past 10 years have any claims, suits or demands been made against the firm, its predecessor or any past or present principal?

11: After inquiry, is the applicant aware of any act, error, omission or circumstance which may possibly result in a claim being made against them? If yes, please explain below:

12: Number of employees who have had at least six hours of continuing education in the past 12 months:

13: What percentage of your projects use written contracts:

For Surveyors Only:

1: Are all registered land surveyors members of ACSM?

2: Services percentage breakdown should total 100%:

a. Subdivision work, topographic, construction stakeout, hydrographic-

b. Engineering Services-

c. All Other Services-

This form is used for quotes only. Coverage is not bound by returning this form.

Choices Insurance Agency-Copyright 2016