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Architects & Engineers Online Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information
First Name
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Last Name
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Company Owner
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Formal Name of Business
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Business Type
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Street
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City
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State
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ZIP / Postal Code
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Primary Phone Number
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Year Business Established
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How many years of experience do you have?
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Website Address:
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Amount of Desired Insurance
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Do you currently have insurance?
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Prior Insurance
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Current Premium
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Current Insurance Provider
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Effective Date
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/ /
Current Policy End Date
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Number of E&O insurance claims filed with insurance carriers in the last 5 years:
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Estimated Gross Annual Fees
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Prior Year Gross Annual Fees
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Number of Architects or Engineers at firm:
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Number of Surveyors or other technical personnel at firm:
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Number of other office staff at firm.
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To what professional associations do the Firm or Principals belong to:
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Does the firm have in-house quality control procedures?
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Does the firm obtain continuing education for professional employees?
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How many professional employees of the firm have attended at least 6 hours of continuing education over the past 12 months?
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Does the firm use written contracts on every project?
Required
if no, provide the percentage of projects where oral agreements were used:
Required
Please specify the appoximate percentage of professional services rendered under AIA or EJCDC standard contracts:
Required
If no standard contract, modified AIA/EJCDC contracts or letter agreements are used, are the reviewed by firm's legal counslet or liability implications prior to signing?
Required
Does the firm seek a limitation of liability clause in contracts with clients?
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If so, what percentage of contracts contain this clause?
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Does the firm subcontract any professional services?
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If yes, please explain:
Optional
Has Professional Liability (E&O) insurance ever been non-renewed or cancelled?
Required
Does the firm currently have E&O insurance in place?
Required
Does the firm currently have General Liability Insurance in place?
Required
If yes, please provide name of General Liabilty insurer and approximate expiration date:
Optional
Has any of the firm's principals or employees ever been the subject of disciplinary action by authorities as a result of their professional activities?
Required
Does the person or firm to be insured have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim against him/her?
Required
How many suits for collection of unpaid fees have been filed by your firm or your employees against a client in the last 2 years?
Required
Advise if your contracts contain these items:
Required


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Does any one contract or client represent more than 25% of your firm's annual work?
Required
Please advise percentages of all areas of practice to equal 100% (e.g. Civil 90%, HVAC 5% Structural 5%)
Required
Based upon billings, please advise percentages of all specific project types to equal 100% (e.g. Condo 10%, 1 Family Dwellings 25%, Office Buildings 15%, Roads 25%, Bridges 25%) )
Required
Please provide % breakdown of all specific activites firm has or will engage in, must add up to 100%. (e.g. design with observation 50%, constuction mgmt 25%, design.build 10%, interior design only 15%)
Required
Please provide % breakdown of all States firm will work in (must add up to 100%)
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E-Mail Address
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How did you hear about us?
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Additional Comments
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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Location
Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755
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