Affinity Insurance Agency, Inc.
Premium Estimate for A & E
TO: Affinity Insurance Agency
3950 Cobb Parkway, Suite 707
Acworth, GA 30101
Tel. 770-974-5502
Fax 770-974-5359
Just give us a few facts about your firm and we can provide you with a premium estimate. We will need to see a fully completed application before we can send you a firm quote, but this should be enough information for a reasonably good estimate.
1. Contact Person:
Firm:
Phone:
Email:
Address:
City: State: Zip:
Fax:
Website:
 

2. What were your firm’s gross annual billings for the past three fiscal years (less direct reimbursable)? Last year: Two years ago: Three years ago:
 

3. What is the total number of staff in your firm? How many registered architects, landscape architects, land surveyors and licensed engineers does your firm employ?
 

4. Based on firm’s annual gross billings from the last fiscal year: provide percentage of billings attributed to following disciplines (excluding your sub consultants):
 
Architect:
Forensic Engineer:
Mechanical Engineer:
Civil Engineer:
Geotechnical Engineer:
Process Engineer:
Construction Manager
Interior Designer:
Structural Engineer:
Electrical Engineer:
Landscape Architect:
Other:
Environmental Consultant:
Land Surveyor:
 

provide percentage of billings derived from each of the following project types/categories (to equal 100%)

Airports:
Hospitals:
Religious:
Amusement Parks:
Hotels/Motels:
Residential (non-condo):
Banks:
Jails/Prisons:
Sewer/Water Systems:
Bridges:
Military Facilities:
Swimming Pools:
Condominiums:
Mines/Quarries:
Toxic/Hazardous Waste Sites:
Educational:
Museums:
Wastewater Systems:
Harbors/Ports/Piers:
Parking Garages:
Other:
Highways/Roads:
Refinery/Petro:
Result:

5. Please specify the percentage of your firm’s projects that are currently being performed under some form of written agreement. %
 

6. Please provide the percentage of your firm’s gross receipts that were paid to sub-consultants that are insured for professional liability. %

7. Please provide the percentage of your firm’s gross receipts from the past year that were derived from feasibility studies, master planning, reports, opinions, interior design and forensic engineering? %

8. Is your firm or subsidiary, parent or other organization related to your firm engaged in:

a. actual construction, fabrication or erection?
YES
NO
b. computer software development for, or sales to, others? 
YES
NO
c. real estate development?               
YES
NO
d. the manufacture, sale, leasing or distribution of any product or production process?
YES
NO
e. pre-purchase home inspections?
YES
NO
f. projects located outside the United States of America?
YES
NO
     


9. Have any professional liability claims been made, incidents reported or legal action brought in the past five years (ten years for firms with gross annual billings greater than $5million) or made earlier and still pending against your firm, its predecessors or any past or present principal, partner, officer, director, shareholder or employee?   YES NO    (If yes and the total incurred including expenses is greater than $10,000, please provide a loss run)


Please provide an explanation if required:


 

10. Firm’s Professional Liability coverage:

Current insurer:
Expiration Date of Policy:
Current Limits:
Deductible:
Current Premium:
 

 

3950 Cobb Parkway, Suite 707 Acworth, GA 30101
Tele. (770) 974-5502 * Fax (770) 974-5359
September 2007