Travelers Insurance Company of Canada	Design Professional Liability Coverage Section Application

The information requested in this application is for claims-made coverage sections. If issued, the claims made coverage sections of the policy cover only claims made against insureds during the policy period or any applicable extended reporting period. Payment of defence expenses will not reduce the limit of insurance except as respects claims brought and maintained in the United States of America.

GENERAL INFORMATION

“Applicant” means all entities, including subsidiaries, for which coverage is requested.

Name of Applicant:
Address:
Web Address:	Email Address:
Telephone Number:	Primary Contact:

DESIGN PROFESSIONAL LIABILITY INFORMATION

1.	Date the Applicant established its business:

2.	Provide a detailed description of the Applicant’s services.

3.	Does the Applicant have any branch offices?	Yes No
If “Yes”, indicate locations:

4.	Has the Applicant performed services for projects outside Canada in the past fiscal year?	Yes No
If “Yes”, complete the table below. If projects are in the United States of America, also indicate which state.
Project Country	Fees for Past Fiscal Year
$
$
If there is more information, continue this table by clicking “Add” above.

5.	Indicate the number of Applicant’s staff.
Staff Type	Total
Principals, Partners, Directors
Licensed Professionals (Architects, Engineers, etc.)
Technical Personnel
Admin

6.	Describe the credentials and ownership interest of the Applicant’s current principals, partners, or sole proprietor.
Name and Title	University Name	Degree	Graduation Year	Professional Designation	Location where Registered to Practice	Ownership Percentage
%
%
%
If there is more information, continue this table by clicking “Add” above.

7.	a. Does any partner, principal, member, officer, director, shareholder, or immediate family member of the Applicant have more than 49% ownership interest in any entity for whom the Applicant performs professional services?	Yes No
b. Does the Applicant have any affiliated companies or predecessor firms for which coverage is requested?	Yes No
If part a. or b. are answered “Yes”, attach details.

8.	Does the Applicant engage in, or assume responsibility for, designing, manufacturing, selling, leasing, or distributing any product, process, or patented design?	Yes No
If “Yes”, attach details of the Applicant’s operations.

9.	Describe the Applicant’s 5 largest projects during the past 5 years.
Client Name	Services Performed	Annual Project Revenue
$
$
$
$
$
If there is more information, continue this table by clicking “Add” above

10.	a. Does the Applicant engage in, or assume responsibility for, actual construction, fabrication, installation, or erection?	Yes No
b. Does the Applicant ever have single-point responsibility for both the design and the construction of a project?	Yes No
If “Yes”, complete the Design/Build Information section on the Design Professional Liability Additional information Form.

DESIGN/build INFORMATION

Complete if Applicant answered “Yes” to question 10 of the Design Professional Liability Coverage Section Application.

1.	How many years of design/build experience does the Applicant have?

2	Select the scenario that best describes the contractual relationship of the design/build activities of the Applicant.
A. Contractor or D/B Entity Prime Client hires contractor or D/B entity (not related to Applicant) as prime, the prime retains the Applicant’s design services under contract (Design Only Responsibility).
B. Multi-Prime Project Client hires Applicant and other A/E firms separately under individual contracts. All A/Es under separate contract to Client. (Design Only Responsibility).
C. Design/Bid/Build or Bridging Client hires Applicant and contractor or D/B entity separately, D/B entity is not related to Applicant (Design Only Responsibility).
D. Applicant Prime Client hires Applicant as prime, the prime acts as single point of contact for the Client and retains contractor’s services for the ‘build’ under contract (Design and Construction Responsibility).
E. D/B Shell Entity Prime Client creates D/B shell entity and hires shell entity as prime; shell entity has no employees and performs no actual design or construction. D/B Shell entity is comprised of in whole or in part by the Applicant and contractor, subcontracts all design and construction to Applicant and contractor (Design and Construction Responsibility).
F. D/B Entity Prime Client hires D/B entity as prime; Applicant and contractor are both employees of D/B entity and perform all design and construction in-house (Design and Construction Responsibility).
G. Other For example: Construction only — no design; Construction management — agency; Construction management — at risk. (Attach details).
D/B entity = Design/Build entity; A/E firm = Architecture/Engineering firm; Contractor = construction trade, Client=project owner

3.	Complete the table with the Applicant’s fiscal year end (“FYE”) design/build information. If Applicant has no historic data, only complete Projected FYE. Indicate negative figures with “( )”or “-“.
Design/Build Information	Projected FYE ( / ) (MON/yyyy)	Most Recent FYE ( / ) (MON/yyyy)
Estimated Construction Values	Professional Fees	Estimated Construction Values	Professional Fees
A. Contractor or D/B Entity Prime	$	$	$	$
B. Multi-Prime Project	$	$	$	$
C. Design/Bid/Build or Bridging	$	$	$	$
D. Applicant Prime	$	$	$	$
E. D/B Shell Entity Prime	$	$	$	$
F. D/B Entity Prime	$	$	$	$
G. Other	$	$	$	$

4.	Does the Applicant have separate insurance coverage for specific projects?	Yes No
If “Yes”, attach details.

5.	Does the Applicant require all its licensed professionals on contract to have their own insurance?	Yes No
If “No”, attach an explanation.

6.	Does the Applicant want to exclude some or all of its licensed professionals on contract from this insurance coverage? (Design Professional Liability automatically provides excess coverage for all licensed professionals on contract.)	Yes No

FINANCIAL INFORMATION

1.	Complete the table with the Applicant’s fiscal year end (“FYE”) financial information. If Applicant has no historic data, only complete Projected FYE. Indicate negative figures with “( )”or “-“.
Financial Information	Projected FYE ( / ) (MON/yyyy)	Most Recent FYE ( / ) (MON/yyyy)	1 Year Prior FYE ( / ) (MON/yyyy)	2 Years Prior FYE ( / ) (MON/yyyy)
Gross Revenues	$	$	$	$
Reimbursable billings and expenses*	$	$	$	$
Separately insured project fees	$	$	$	$
Billings from licensed professionals on contract (with own professional liability insurance)	$	$	$	$
Annual Gross Billings	$	$	$	$
*includes non-professional services or expenses that are reimbursed under the terms of a client contract (i.e. travel) Do not include sales and service taxes, interest income, rental income on real estate, or revenues that are not part of Applicant’s professional services.

2.	Has the Applicant ever filed for, or been in, receivership or bankruptcy?	Yes No
If “Yes”, attach details.

TYPE OF SERVICES

1.	Provide the percentage of Annual Gross Billings by discipline for the Applicant’s most recent fiscal year end: (Check all that apply.) From Financial Information question 1
Discipline	Percentage of Annual Gross Billings	Discipline	Percentage of Annual Gross Billings
Civil Engineer	%	Architect	%
Mechanical Engineer	%	Architectural Planner	%
Electrical Engineer	%	Interior Designer	%
Structural Engineer	%	Landscape Architect	%
Environmental Engineer/Scientist*	%	Land Surveyor**	%
Geotechnical Engineer (soil materials & mechanics)	%	Construction Manager	%
Geotechnical DCL (drilling, compaction, lab work & testing)	%	Other*** (attach details)	%
*Complete the Environmental Engineer/Scientist Information section on the Design Professional Liability Additional information Form. **Complete the Land Surveyor Information section on the Design Professional Liability Additional information Form. ***For example, unlicensed construction and design consultants, such as acoustical consultants

2.	Provide the percentage of Annual Gross Billings by project type for the Applicant’s most recent fiscal year end: (Check all that apply.) From Financial Information question 1
Project Type	Percentage of Annual Gross Billings	Project Type	Percentage of Annual Gross Billings
INDUSTRIAL	Parking garages	%
Chemical, refinery, underground storage tanks	%	Office buildings, warehouses, retail stores, malls, banks	%
Asbestos, lead, mould, & radon abatement	%	Fast track	%
Dams, mines, quarries, tunnels	%	Feasibility studies	%
INFRASTRUCTURE	%	RESIDENTIAL*	%
Bridges, trestles	%	Multi-unit condominiums, hotels, motels, apartment buildings, cooperatives over 15 storeys	%
Docks, harbours, piers, ports	%
Roads, highways	%	Custom homes, single family homes, townhomes	%
Utilities	%
COMMERCIAL	%	INSTITUTIONAL	%
Commercial high rise or buildings over 15 storeys	%	Hospitals, healthcare or assisted living facilities	%
Sports complexes, arenas, stadiums, theatres	%	Other (attach details)	%
*Complete the Residential Project Information section on the Design Professional Liability Additional information Form.

3.	Provide the percentage of Annual Gross Billings by client type for the Applicant’s most recent fiscal year end: (Check all that apply.) From Financial Information question 1
Client Type	Percentage of Annual Gross Billings	Client Type	Percentage of Annual Gross Billings
Contractors	%	Private Owners	%
Public Sector (federal, provincial, state, or local government)	%	Design Professionals	%
Developers	%	Other (attach details)	%

4.	Is more than 25% of Annual Gross Billings for the Applicant’s most recent fiscal year end derived from a single client?	Yes No
If “Yes”, attach details.

5.	How much of the Applicant’s business is with repeat clients?	%

LAND SURVEYOR INFORMATION

Complete if Applicant selected “Land Surveyor” on question 1 of the Design Professional Liability Coverage Section Application.

1.	Indicate the number of Applicant’s staff who are Land Surveyors.
Staff Type	Licensed Land Surveyors	Licensed Land Surveyors with Provincial Association Membership	Commissioned Canada Land Surveyors
Principals, Partners
Employees

2.	Provide the percentage of Annual Gross Billings by land surveyor service for the Applicant’s most recent fiscal year end: (Check all that apply.) From Financial Information question 1
Land Surveyor Service	Percentage of Annual Gross Billings	Land Surveyor Service	Percentage of Annual Gross Billings
Construction Layouts	%	Oil & Gas Surveys	%
Geodetic Surveys	%	Percolation Tests, Septic & Sewage Systems (domestic & commercial)	%
Geomatic Engineering Survey	%
Legal Surveys	%	Seismic Surveys	%
Marine Surveys	%	Topography & Mapping	%
Mining Surveys	%	Other (attach details)	%
Mortgage Certificate	%

3.	Does the Applicant currently use drone technology to perform professional services?	Yes No
If “Yes”, attach details.

RISK MANAGEMENT INFORMATION

1.	Provide the percentage of total contracts by contract type for the Applicant’s most recent fiscal year: (Check all that apply.)
Contract Type	Percentage of All Contracts	Contract Type	Percentage of All Contracts
Applicant’s Standard Drafted Contract	%	Client Drafted Contract	%
Applicant’s Standard Letter of Agreement	%	Purchase Order	%
Professional Association Contract	%	Verbal Agreement	%

2.	Is a limitation of liability provision incorporated into all of the Applicant’s contracts and agreements?	Yes No
If “No”, describe what steps the Applicant takes to protect itself against unfavourable contract language.

3.	Does the Applicant use a written contract with:
a. all clients?	Yes No	b. all licensed professional on contract?	Yes No
If part a. or b. are answered “No”, indicate the percentage of written contract usage for:
c. clients	%	d. licensed professionals on contract	%

insurance INFORMATION

1.	Current Carrier	Current Limit	Current Retention	Current Premium	Date First Purchased (dd/MON/yyyy)
$	$	$

2.	Coverage Requested	Requested Limit	Requested Retention
Design Professional Liability	$ per Claim $ aggregate	$ per Claim

3.	Has any person or entity proposed for this insurance ever been declined or had such insurance not renewed or cancelled, including for non-payment of premium?	Yes No
If “Yes”, attach an explanation.

loss information

1.	Is the Applicant, or any person proposed for this insurance aware of any fact, circumstance, situation, event, or act involving professional services that reasonably could give rise to a claim against them under the Liability Coverage for which the Applicant is applying?	Yes No
If “Yes”, please attach an explanation.
As respects the information required to be disclosed in response to the questions above, the proposed insurance will not afford coverage for any claim arising from any fact, circumstance, situation, event or act about which any executive officer of the Applicant had knowledge prior to the issuance of the proposed policy, nor for any person or entity who knew of such fact, circumstance, situation, event or act prior to the issuance of the proposed policy.

2.	Has any person or entity proposed for this insurance been: (i) a party to any professional liability claims; (ii) a party to any disciplinary actions; or (iii) cited by any regulatory agency or professional association; during the past 5 years?	Yes No
If “Yes”, please complete the table below:
Claim 1	Date (dd/MON/yyyy)
Nature of Claim
Amount Paid for Defence	$	Amount Sought or Paid for Damages	$	Covered by Insurance?	Yes No
Corrective Procedures Implemented
Current Status
If there are more claims, continue this table by clicking “Add” above.

REQUIRED ATTACHMENTS

1.	As part of this Application, please submit the following documents:.
a. Copies of standard contracts and services agreement letter used with clients.
b. Resumes of all principals, partners, and key employees if in business less than 5 years.
c. Copy of the Applicant’s professional liability loss runs for the past 5 years. These documents, and the representations and facts they contain, are made a part of this Application, whether such documents are physically delivered to Travelers by the Applicant or are obtained by Travelers from any public source, including the Internet.

SIGNATURE AND PRIVACY CONSENT

1.	The undersigned Authorized Representative represents that to the best of their knowledge and belief, and after reasonable inquiry, the statements provided in response to this Application and all attached Coverage Section Applications, including Supplemental Applications (collectively, “the Application”), are true and complete, and may be relied upon by Travelers Insurance Company of Canada as the basis for providing insurance. The Applicant will notify Travelers Insurance Company of Canada of any material changes to the information provided. This Application, including any requested or submitted information, will be deemed attached to and form a part of any policy issued.

2.	The undersigned Authorized Representative hereby consents to the collection, use, and disclosure of:

a.	the undersigned’s personal information; or

b.	the personal information of a third party (such as a family member, director, officer, or employee); and the undersigned represents they have obtained that person’s consent to such collection, use, and disclosure in accordance with Travelers Insurance Company of Canada’s Privacy Policy*;

in the ordinary course of business:

(1)	for the purposes of underwriting bonds, policies of insurance, and all other related insurance products offered by Travelers Insurance Company of Canada and all related documentation, bond, or policy management (which includes: handling customer complaints; any activities associated with extensions, renewals, substitutions, and modifications of such bond or policy of insurance; and claims administration); or

(2)	by and to its affiliates, reinsurers, legal advisors, other financial institutions, regulatory bodies, and any third party deemed necessary by Travelers Insurance Company of Canada.

*Travelers Insurance Company of Canada’s Privacy Policy is available online at www.travelerscanada.ca. If you have any questions about our Privacy Policy, contact our Privacy Officer at 1.800.268.8447 or 416.362.7231.

Authorized Representative Signature*: (President or CEO) X	Authorized Representative Name and Title	Date (dd/MON/yyyy):

*If you are electronically submitting this document, apply your electronic signature to this form by checking the Electronic Signature and Acceptance box below. By doing so, you agree that your use of a key pad, mouse, or other device to check the Electronic Signature and Acceptance box constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as a signature affixed by hand.

Electronic Signature and Acceptance – Authorized Representative