Zolofra Insurance
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Toll Free: (888) 858-1777
Fax: (732) 334-0405
Email: Ben@allprocoverage.com





Firm Name

Street Address

City

County

State

Zip Code

Contact Name

Contact Phone Number

Contact Fax Number

Contact Email Address

Tax ID#

Type of business formation:

Have you moved or changed your firm name within the last 5 years?

If yes, please explain:

Description of your practice:

What year was the firm established?

A principal of our firm is a licensed architect or engineer.

Our firm is in private practice.

Our firm has not had a claim in the past 5 years.

Our firm employs 12 or fewer people (part-time or full-time.

Our firm is willing to use some for of written agreement on all projects.

Our firm or any member of the firm has never had a professional liability policy cancelled (except for nonpayment of premium) or been non-renewed by any insurance company

Our firm is NOT a soils, process, chemical, nuclear, marine or mining engineering firm; a product design firm; a home inspection firm; an asbestos abatement contractor, or a machinery/equipment design firm.

Less than 10% of our firm’s billings (either this year or next) are derived from pollution cleanup, remediation or containment, underground storage tanks, air emission controls, landfills, superfund sites, environmental permitting or industrial piping

If ANY of your firm’s services are rendered in these areas (either this year or next), please indicate project(s) type:

and the percentage of your firm’s billings for each service:

Less than 20% of our firm’s billings are derived from Design/Build projects where we, or a related entity, accept responsibility for actual construction by in-house personnel or subcontractors.

If ANY (either this year or next), please indicate the percentage:

Less than 10% of our firm’s billings are derived from asbestos related services or condominium projects.

If ANY (either this year or next), please indicate the percentage for:

Asbestos:

Condos:

Do you specify Exterior Insulation and Finishing Systems (EIFS) on your projects?

If ANY (either this year or next), please indicate the percentage of projects in the past year:

GROSS billings for the past 3 fiscal years. (include consultants fees you pass on to others, uncollected fees and reimbursable expenses).

Most recent year:

Past fiscal year:

Two years prior:

Please indicate the approximate percentage of the most recent gross billings mentioned above, if any, derived from the following categories only (if 0%, enter 0%):

1.Feasibility Studies Reports and Opinions, 2.Non-structural Interior Designs, 3.Master Plans, 4.Landscape Architecture, 5.Land Surveying, 6.Direct Reimbursable

Please indicate the approximate percentage of the most recent gross billings, if any, for projects insured under:

Project Policies: $

Specific Additional Limit of Liability Endorsement: $

Specific Additional Limit of Liability Endorsement:

Members of our firm belong to:

 AIA NSPE/PEEP ACEC ASME Other

If other associations, please advise:

Areas of practice, by percentage (Must add up to 100%)

Architecture,
Civil Engineering,
Construction Management, Electrical Engineering,
Full Service A&E Firm,
HVAC Engineering:
Mechanical Engineering,
Sanitary Engineering,
Structural Engineering,
Transportation Engineering, Surveying, OTHER – please describe practice(s)

Projects, please list: (Must add up to 100%)

Commercial Buildings,
Education,
Healthcare,
Residential,
Industrial, Manufacturing,
Religious,
Roads/Transportation, Sewerage/Water,
Other – Public Sector,
Other – Private Sector:, Other(Anything else, please list)

Total staff, including Principals, Partners, or Officers. (use .5 for part-time staff)

Regarding staff, please provide a breakdown for the following (use .5 for part-time staff)

Principals, Partners or Officers that are Licensed Architects:

Principals, Partners or Officers that are Licensed Engineers:

Principals, Partners or Officers that are part of the Technical Staff:

Principals, Partners or Officers that are part of the Administrative Staff:

Employees that are Licensed Architects:

Employees that are Licensed Engineers:

Employees that are part of the Technical Staff:

Employees that are part of the Administrative Staff:

We currently carry Professional Liability coverage.

Our current insurance company is:

Our current policy expires on (mm/dd/yyyy):

We have continuously carried coverage for:

We have a policy endorsement giving full prior acts coverage.

Retroactive coverage date in current policy (mm/dd/yyyy):

After inquiry, do you have knowledge of any error, omission, unresolved job dispute (including owner-contractor disputes), accident or any other circumstance that is or could be the basis for a claim under the proposed insurance policy?

If you have had a claim or have knowledge of a future claim, please provide full details below. Please include date of incident, date reported to carrier, name of carrier, name of injured party, description, amount paid and/or reserved. Closed?

Additional Comments:

Disclaimer Notice – The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Please utilize the “Send” Button to send your form to our office. If the website does not allow you to submit the form, please print the page and fax it to 732.334.0405 or scan it into your computer and send it to ben@allprocoverage.com. Do not “Refresh” the page because all data entered onto the form will be lost.

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Zolofra Insurance Agency
P.O. Box 8787
Red Bank, NJ 07701
Toll Free: (888) 858-1777
Direct: (732) 542-1757
Fax: (732) 334-0405
Email: Ben@allprocoverage.com
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