Beazley AFB AAMPAMPE Media Tech Renewal Application

AFB A&E MEDIA TECH® RENEWAL APPLICATION

ARCHITECTS AND ENGINEERS PROFESSIONAL LIABILITY, ARCHITECTS, ENGINEERS AND CONTRACTORS POLLUTION LIABILITY, TECHNOLOGY BASED SERVICES, TECHNOLOGY PRODUCTS, COMPUTER NETWORK SECURITY, AND MULTIMEDIA AND ADVERTISING AND PRIVACY LIABILITY INSURANCE POLICY

Important Note: THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. Subject to its terms, the Policy applies only to a Claim first made against the Insureds during the Policy Period or the Optional Extension Period (if purchased) and reported in writing to the Insurer during or within 60 days after expiration of the Policy Period or during the Optional Extension Period (if purchased). Claim Expenses will reduce and may exhaust the Limit of Liability available to pay Claims and are applied to the deductible. The Insurer will not pay settlements or judgments after the Limit of Liability is exhausted by payment of Damages or Claim Expenses.

Additional Notice To New York Applicants: The Policy for which this Application is made is a claims made policy. The Policy provides no coverage for Claims arising out of incidents, occurrences or wrongful acts which took place prior to the Retroactive Date. Upon termination of coverage for any reason, a 60-day automatic extension period will apply. For an additional premium, a three year Optional Extension Period can be purchased.

Additional Notice to Minnesota Applicants: Under Minnesota law a Claim may be reported orally or in writing to the Insurer or to the Insured’s Broker of Record.

Please fully answer all questions and submit all requested information. Terms appearing in bold face in this Application are defined in the Policy and have the same meaning in this Application as in the Policy. If you do not have a copy of the Policy, please request it from your agent or broker. Firm agrees that the representations made in this Application and any supplemental attachments, are material and have been relied upon by the Underwriter in issuing any Policy.

Applicant Information

1. Firm Name:

2. Any changes to the firm address during the past 12 months? Yes No

If no, please skip to question 3
If yes, please complete the table below

Address: City: State: Zip Code:

3. Staff Information:

Total # of staff at the firm, including part-time employees:

How many architects, landscape architects, land surveyors, or licensed engineers does your firm employ?

Does the firm have at least 1 principal that is a licensed professional? Yes No

How many people left the firm in the past 12 months?

Management Staff

Professional Employees

Financial Information

4. Fee Information:

Practice Information

5. Any changes to the firm’s professional services during the past 12 months? Yes No

If no, please skip to question 6
If yes, please complete the table below. (Total Must Equal 100%)

6. Any changes to the firm’s service types listed below during the past 12 months? Yes No

If no, please skip to question 7
If yes, please complete the table below (Total Must Equal 100%)

7. Is your firm or any subsidiary, parent or other organization related to your firm engaged in any of the following?

8. Any changes to the firm’s project mix during the past 12 months? Yes No

If no, please skip to question 9
If yes, please complete the table below (Total Must Equal 100%)

9. Firm’s 3 largest current projects during the past 12 months:

10. Project Size – List by project construction value for the past 12 months (Total Must Equal 100%):

11. Any condominium projects in the past 5 years? Yes No

Clients

12. Any international projects in the past 12 months? Yes No

If yes, please provide percentage of revenues attributable to such services:

Countries in which services are performed:

13. Any changes to the firm’s client mix during the past 12 months? Yes No

If no, please skip to question 14
If yes, please complete the table below. (Total Must Equal 100%)

14. Percentage (%) of the firm’s services during the past 12 months derived from repeat clients:

Risk Management

15. Any changes to the firm’s risk management practices or procedures during the past 12 months? Yes No

16. Has the firm participated in a Beazley risk management webinar within the past 12 months? Yes No

If yes, please provide the date(s) of the seminar(s):

17. Any changes to the firm’s use of contracts during the past 12 months? Yes No

18. Percentage (%) of firm’s contracts use of limitation of liability provisions, where the firm’s liability is limited to $250,000 or less

19. Has the firm conducted an external peer review during the past 12 months? Yes No

Claim and Circumstance Information

20. Has the firm brought a lawsuit against any clients to collect fees owed to the firm in the past 3 years?

21. Does the firm currently have any unresolved fee disputes?

22. Has any Claim or legal action been brought against the firm, its predecessor(s) or any past principal, partner, director, or officer in the past 5 years other than what has already been reported to its prior or current professional liability insurance carrier(s)? Yes No

23. After inquiry, is the firm, its predecessor(s), or any other person or entity for which coverage would be provided aware of any Circumstance(s) that would suggest to a reasonable person that a Claim might possibly be made? Yes No

NOTHING CONTAINED HEREIN OR INCORPORATED HEREIN BY REFERENCE SHALL CONSTITUTE NOTICE OF A CLAIM OR POTENTIAL CLAIM SO AS TO TRIGGER COVERAGE UNDER ANY CONTRACT OF INSURANCE. IF APPLICANT INTENDS TO SEEK COVERAGE FOR ANY CLAIM OR CIRCUMSTANCE REFERENCED HEREIN, APPLICANT MUST STRICTLY FOLLOW THE TERMS AND CONDITIONS OF THE APPLICABLE POLICIES.

Email: Phone: Fax:

FRAUD WARNING DISCLOSURE

ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT (S)HE IS FACILITATING A FRAUD AGAINST THE INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD.

Additional state notices appear in the PDF for Alabama, Arkansas, Louisiana, New Mexico, Rhode Island, Colorado, District of Columbia, Florida, Kansas, Maine, Tennessee, Virginia, Washington, Maryland, Oklahoma, Kentucky, New Jersey, New York, Ohio, and Pennsylvania.

Signature Section

THE UNDERSIGNED AUTHORIZED EMPLOYEE OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. The undersigned agrees to notify the Underwriter of any changes prior to the Effective Date of insurance.

If this Application is completed in Florida, please provide the Insurance Agent’s name and license number. If this Application is completed in Iowa or New Hampshire, please provide the Insurance Agent’s name and signature only.

Agent’s Printed Name: Florida Agent’s License Number:

Agent’s Signature*: