CHILDRESS | PRICE
INSURANCE
dba:DEAN MORRIS INSURANCE SERVICES, INC.

Named Insured

Street Address

Zip/Postal Code		Contact Name		Contact Phone
E-mail		Website

CURRENT POLICY INFORMATION
Professional Liability: (If Applicant does not currently have Professional Liability coverage, please provide requested term, limits, and deductible.)

Insurance Company

Policy Term

Current Premium

Limits (Per Claim) $

Limits (Aggregate) $

Deductible

General Liability: (If Applicant does not currently have Professional Liability coverage, please provide requested term, limits, and deductible.)

Insurance Company

Policy Term

Current Premium

UNDERWRITING INFORMATION

Date Established

# of Licensed Professionals

Gross Fees

Subcontracting Fees

Reimbursables

Current Year	$	$	$
1st Year Prior	$	$	$
2nd Year Prior	$	$	$
3rd Year Prior	$	$	$
4th Year Prior	$	$	$
5th Year Prior	$	$	$
Current Year represents services rendered from		to

Named Insured is	Corporation Partnership Professional Corporation Sole Proprietorship Other
If other please specifiy

Areas of Practice
Based on the Applicant's gross billings, indicate the type of services performed. Do not include services performed by others on your behalf. (Total must equal 100%)

	% Accoustical Engineering		% Forensic Engineering		% Naval / Marine
	% Architecture		% Geotechnical Engineering		% Nuclear Engineering
	% Chemical Engineering		% HVAC Engineering		% Process Engineering
	% Civil Engineering		% Hydrological Engineering		% Structural Engineering
	% Communication Engineering		% Interior Design		% Testing Labs
	% Construction Management		% Land Surveying		% Other
	% Electrical Engineering		% Landscape Architecture
	% Environmental Enginnering		% Mechanical Engineering

Activities
Based on the Applicant's gross billings, indicate the type of activities performed.(Total must equal 100%)

	% Construction Management		% Feasibility Studies
	% Construction with Design Subcontracted		% Observation of Construction Only
	% Design with Construction		% Surveying
	% Design with Observation		% Other

Project Types
Based on the Applicant's gross billings, indicate their types of projects. (Total must equal 100%)

Residential

Commercial

	% Amusement Rides		% Manufacturing		% Sewage Systems
	% Arenas / Stadiums		% Mass Transit		% Shopping Centers
	% Bridges		% Municipal Buildings		% Superfund / Pollution
	% Churches		% Nuclear Atomics		% Telecommunications
	% Convention Centers		% Office Buildings		% Theatres
	% Dams		% Parking Structures		% Tunnels
	% Harbors / Piers / Ports		% Petrols / Chemicals		% Utilities
	% Hospitals / Healthcare		% Pools		% Warehouses
	% Hotels / Motels		% Pre-Engineered Buildings		% Wastewater / Sewage Treatment Plants
	% Jails		% Recreation / Playgrounds		% Water Systems
	% Landfills		% Roads / Highways		% Other
	% Libraries		% Schools / Colleges

Claims History
Attach to this Application currently valued loss runs from prior carriers.

1. Has any claim been made or legal action been brought in the past ten years (or made earlier and still pending) against the Applicant? If "yes," please provide details below.	Yes No
2. Are there any circumstances, incidents, situations or accidents during the past ten years which may result in claims being made against the Applicant? If "yes," please provide details below.	Yes No
3. Are there any deficiencies or alleged deficiencies in work where the Applicant performed professional services or are there any deficiencies or alleged deficiencies in work by others for whom the Applicant is legally responsible during the last five years? If "yes," please provide details below.	Yes No
4. Does the Applicant have knowledge of injury to people or damage to property during the past five years on or at projects where the Applicant has rendered professional services? If "yes," please provide details below.	Yes No

If you answered "yes" to any of the above questions plese provide the details.

Additional Underwriting Information
1. List below the Applicant's five largest projects in the last three years.

Project

Fees

Construction Value

	$	$
	$	$
	$	$
	$	$
	$	$

2. Is the Applicant or any subsidiary, parent or other organization related to the Applicant involved in:

	a. Actual construction, fabrication or erection?	Yes No
	b. Development, sale or lease of computer software to others?	Yes No
	c. Real estate development?	Yes No
	d. Manufacturing, sale, leasing or distribution of any product?	Yes No

3. Are any of the principals, partners, officers, directors or employees of the Applicant involved in any activities described in question #2 above? If "yes," please provide details below. Include a description of the service performed, any construction value involved and fees received.	Yes No
4. Is the Applicant controlled, owned or associated with any other firm, corporation or company, or does the Applicant own or control any other entity? If "yes," please provide details below.	Yes No
5. Does the Applicant render services on behalf of any entity in which any principal, partner, officer, director or employee of the Applicant, or an immediate family member of such persons is a principal, partner, officer, director or employee? If "yes," please provide details below.	Yes No
6. Has the Applicant ever been subject to disciplinary action by authorities as a result of their professional activities? If "yes," please provide details below.	Yes No

If any of the above answers are "yes," please provide details below.

Signature Section

APPLICANT REPRESENTS THAT THE STATEMENTS AND FACTS IN THIS APPLICATION ARE TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED.
Applicant acknowledges a continuing obligation to report to us as soon as practicable any changes in the facts or statements show above or in any supplementary application.
COMPLETION OF THE FORM DOES NOT BIND COVERAGE.  APPLICATN’S ACCEPTANCE OF COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE.  IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED AND IT WILL BE ATTACHED TO AND BECOME PART OF THE POLICY.
Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties. 
We hereby declare that the above statements and particulars are true and I/we agree that this application shall be the basis of the contract with the insurance company.

For the most accurate quote, please attach your current insurance information (declaration page with coverage information)

Comments / Questions: