Beazley Specific Project Client Excess Limit of Liability Application

Specific Project/Client Excess Limit of Liability 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).

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.

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.

Applicant Information

1. Firm Information

Firm Name:

Project Name:    Project Location:

Client Name:    Contract Number:

2. Estimated beginning and completion dates for both the design and construction phases:

3. Description of the firm’s services for the project:

4. Description of the project:

5. Total estimated construction value for the project: $

6. Total estimated fees the firm will receive for this project only: $

7. Annual breakdown of the firm’s project fees for this project only:

8. Total estimated contract fees for all design firms for this project: $

9. Who is the prime design professional for this project?

10. Total Each Claim and Aggregate limits required? $ Each Claim / $ Aggregate

11. How long is the firm required to carry this limit?

12. Has the firm performed design services for this client in the past? Yes No

If yes, please provide project names below.

Claim and Circumstance are defined as follows for the purposes of question 13.

Circumstance means any fact, event or situation that could reasonably be the basis for a Claim.

Claim means a demand for money or services including the service of suit or institution of arbitration proceedings.

13. Is the firm, its predecessor(s), or any other person or entity for which coverage would be provided aware of any Claim(s) or Circumstance(s) on this project? Yes No

If yes, please attach details below:

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.

A Copy of the Contract may be required with this Application

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.

NOTICE TO ALABAMA, ARKANSAS, LOUISIANA, NEW MEXICO AND RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO KANSAS APPLICANTS: Any person who knowingly and with intent to defraud presents or prepares a written statement as part of an application for insurance that contains materially false information commits a fraudulent insurance act.

NOTICE TO MAINE, TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.

NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime.

NOTICE TO OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO KENTUCKY, NEW JERSEY, NEW YORK, OHIO AND PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information commits a fraudulent insurance act.

Signature Section

The undersigned authorized employee of the applicant declares that the statements set forth herein are true. The undersigned authorized employee agrees that if the information supplied on this application changes between the date of this application and the effective date of the insurance, he/she will immediately notify the underwriter of such changes.

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.

Signing of this application does not bind the applicant or the underwriter to complete the insurance, but it is agreed that this application shall be the basis of the contract should a policy be issued.

Electronic Signature and Acceptance – Firm’s Authorized Representative Date:

Electronic Signature and Acceptance – Insurance Agent/Broker/Producer Date:

Firm’s Authorized Representative Printed Name:    Title:

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*: