Application Errors and omissions insurance for project managers of construction projects

Project managers 500-1400 Blair Towers Place • Ottawa ON K1J 9B8 • 1-800-267-6684 • victorinsurance.ca

Application

Errors and omissions insurance for project managers of construction projects

Applications can be submitted to [email protected]. Submitting broker, please complete

the following to assist us in processing this submission:

Name of brokerage:

Name of broker contact:

Brokerage address: City: Postal code:

For renewal purposes only: Policy number: ISN (Client’s number):

Insurance issued subsequent to this application would insure project managers of construction projects only in

circumstances wherein their agreement with the project owner DOES NOT MAKE THEM ASSUME CONTRACTUAL

RESPONSIBILITY FOR ACTUAL CONSTRUCTION OF THE PROJECT. Otherwise, application should be made for

either Design-build or Contractors Errors and Omissions Insurance.

The applicant

1. Name of applicant:

2. Address of head office:

3. Date established (dd/mm/yyyy): Telephone: Facsimile:

4. Location of branch offices:

5. Predecessor firms:

6. Total number of: Project management professionals (with designation):

Engineers: Architects:

Technical Personnel: Others:

Names of partners, active

directors (include sole

practitioner)

University

attended

Degree

obtained

Year of

graduation

Ownership

in firm

Province or state

in which

registered to

practice

Please attach the curriculum vitae of those listed above.

8. Please list any association memberships of the firm:

9. Is the project management “team” for each project supervised by a professional architect, engineer, architectural

technologist or engineering technologist? YES NO

If no, please provide the curriculum vitae of “team” supervisors not qualified as such.

Insurance

10. Has the applicant or predecessor firm previously carried errors and omissions insurance? YES NO

Company Limit Deductible

Expiry date

(dd/mm/yyyy)

Previous Insurer $ $

Present Insurer $ $

Project managers 500-1400 Blair Towers Place • Ottawa ON K1J 9B8 • 1-800-267-6684 • victorinsurance.ca

11. Previous insurance—Has any application for insurance been made on behalf of the applicant or any of the present

partners, officers, directors or employees or, to the knowledge of the firm, on behalf of their predecessors in

business, been declined or cancelled, or has renewal been refused in the past five years? YES NO

If yes, please provide details:

12. Please indicate the limit and deductible required.

$250,000 per claim/$500,000 annual aggregate

$500,000 per claim/$1,000,000 annual aggregate

$1,000,000 per claim/$1,000,000 annual aggregate

$2,000,000 per claim/$2,000,000 annual aggregate

$3,000,000 per claim/$3,000,000 annual aggregate

$4,000,000 per claim/$4,000,000 annual aggregate

$5,000,000 per claim/$5,000,000 annual aggregate

$5,000

$10,000

$25,000

$50,000

Other deductible: $

13. In the firm’s capacity as project manager, does the applicant usually request proof of professional liability insurance

from architectural and engineering consultants rendering services in connection with projects? YES NO

If yes, please indicate the approximate percentage of contracts or mandates undertaken during the last 12 months

for which proof of insurance was obtained from such consultants: __________%.

Fee breakdown

14. Fee income (excluding disbursements):

Last 12 months

or last fiscal

year

Anticipated

next 12 months

or next fiscal

year

(a) Gross fees [include all amounts in 14 (b) to 14 (g)] $ $

(b) Fees emanating from projects for which the applicant IS NOT

CONTRACTUALLY RESPONSIBLE for project DESIGN

$ $

CONTRACTUALLY RESPONSIBLE for project DESIGN $ $

(d) Fees emanating from projects for which the applicant IS

CONTRACTUALLY RESPONSIBLE for ACTUAL project

CONSTRUCTION

$ $

(e) Fees emanating from projects and joint ventures separately insured $ $

(f) Fees emanating from projects or services performed in the U.S.

(CAN $) $ $

(g) Fees emanating from projects or services performed outside of

Canada or the U.S. (CAN $) $ $

15. Total construction values: $ $

Projects

16. (a) Please indicate the percentage of gross fees derived from the following:

Projects Percentage

Services not resulting in construction %

Buildings (excluding industrial) %

Industrial buildings %

Municipal (water, sewage, etc.) %

Heavy civil (bridges, dams, tunnels) %

Light civil, roads %

Marine %

Aviation %

Environmental %

Other (specify) %

Total 100%

Project managers 500-1400 Blair Towers Place • Ottawa ON K1J 9B8 • 1-800-267-6684 • victorinsurance.ca

(b) Do more than 25% of the applicant’s fees emanate from a single client? YES NO

If yes, please provide the client’s name:

Other activities

17. Does the applicant or any related company engage in actual construction, installation or erection?YES NO

18. Does the applicant or any related company engage in actual manufacture, fabrication or assembly?

YES NO

19. Does the applicant or any related company assume responsibility for any of the activities mentioned in questions

17 and 18 above? YES NO

If the answer is “yes” to any of questions 17, 18 or 19, full details of operations must be provided.

Knowledge of prior errors or claims

20. Does the applicant or any of its partners, officers, directors or employees have any knowledge or information of:

(a) any error, omission or negligent act in the performance of professional services for others? YES NO

(b) any written or oral demand for money or any written or oral allegation of breach in the rendering or failure to

render professional services (in the last five years)? YES NO

(d) having been called upon to make any payment or to forego any claim for fees as a result of any job dispute

during the past five years? YES NO

(e) their licence having been suspended or their having been fined or reprimanded during the past five years?

YES NO

In the event that the answer “yes” is given to any of the above questions, please provide full details of the

circumstances.

Without limitation of any other remedy of the insurers, it is agreed that, if the answer “yes” is given to any of the

questions in 20, any claim arising from the facts or circumstances reported therein are excluded from coverage.

Additional information

21. Please list details of projects/joint ventures insured separately:

Name of project/joint venture

Location Insurer Policy term

22. If a new applicant, please attach a list of the 10 largest projects completed in the applicant’s capacity as a project

manager during the past five years using the following format and attach recent company brochures:

Name of project Location Insurer Policy term

Project managers 500-1400 Blair Towers Place • Ottawa ON K1J 9B8 • 1-800-267-6684 • victorinsurance.ca

Applicant’s consent to the transmission of the information contained in the application form

I hereby acknowledge that the information collected in the application form is acquired by my insurance broker to be

transmitted to Victor Insurance Managers Inc. for the sole purpose of obtaining an insurance policy, and will be kept

confidential.

Moreover, I authorize Victor Insurance Managers Inc., its insurers or service providers to:

• conduct verification, using outside sources, of the information contained in the application form, in attached

documentation and in subsequently provided documentation;

• in the event of a claim, transmit the submitted and verified information to loss adjusters, lawyers or other similar

offices for the purposes of investigating, defending, negotiating or settling any claims, as required.

I acknowledge that specific details of Victor’s Privacy Notice can be found at www.victorinsurance.ca.

Declarations and signature

The applicant has read the foregoing and understands that completion of this application does not bind the insurer or

the broker to complete the insurance on the terms requested or at all. Terms and conditions of coverage are as set out

in the policy without reference to the terms and conditions requested in the application herein or otherwise.

The applicant declares and warrants that he/she has made reasonable efforts to obtain sufficient information from each

prospective insured under the policy to fully and accurately complete this application, that this application is complete

and correct to the best of their knowledge and belief, and that all particulars which may have a bearing upon the

applicant’s acceptability as a professional liability insurance risk have been revealed. It is agreed that the answers to

the questions herein shall be binding on all insureds under the policy. It is understood that this application shall form

the basis of the contract should the insurer approve the coverage and should the applicant be satisfied with the insurer’s

quotation.

It is further agreed that if, in the time between submission of this application and the requested date for coverage to be

effective, the applicant becomes aware of any information which would change the answers furnished in response to

question 20 of this application, such information shall be revealed immediately in writing to the insurer.

Signature of applicant (authorized representative) Date (dd/mm/yyyy)