1.     Name of applicant:   

                        Address:

2.    Limit of liability desired:

3.    Deductible:

4.   Please describe in detail the professional activities for which coverage is desired:

5.   Is the applicant engaged in any business or profession other than as described in Item 4?

               Yes    No                                                                

        If YES, please Explain and include estimated revenues:

   6.  List the total gross revenues for the past two years derived from those activities in Question 4.

        In addition, please list projected revenues for the current year.

            Year                                        Amount

a.                       

b.                       

7.      For the revenues listed in question 6.a., please give the approximate percentage derived from each of the activities listed in Question 4:

            Activity                                                                                                             % of 6.a. receipts

8.    Applicant is:        Corporation          Partnership          Individual

9.          Year Established:   

10.       Is the Applicant Firm controlled, owned or associated with any other firm, corporation or company? 

            Yes No           

            If YES, please explain:

           Are any activities listed in Question 4 provided to such business enterprise?          Yes    No              

11.       a.     Number of principals, partners, officers and professional employees directly engaged in providing services

                    to clients:

            b.     Number of non-professional employees (clerks, secretaries, etc.):

12.     Please provide the following:

13.     To what professional association(s) does the Applicant Firm belong?

14.     Please include a list of Applicant Firm's five (5) largest jobs or projects during the past three (3) years.

           Please give, in detail: 1) project/client name; 2) the nature of the services performed for the client; and

           3) the revenues obtained from those services.

15.    Does the Applicant Firm use a written contract with client    In all cases        Sometimes        Never

          Please e-mail a copy of your standard contract(s) to vrakos@ftpins.com .

16. What percentage of the Applicant Firm's business involves subcontracting of work to others?   

        Does the Applicant Firm provide professional services to business entities in which it retains an ownership interest?                Yes    No

        If YES, please explain:

17. Has any similar insurance ever been declined or cancelled?          Yes    No        

        If YES, please explain:

18. Is similar insurance currently in force?            Yes    No                      

        If YES, please provide:

        Description of services being covered:

    Name of Insurer:

    Expiration Date:                               Prior Acts/Retro. Date:

    Limit:                 Deductible:                 Premium:
    Length of time coverage has been in force:

19. Please send most recent audited financial statements (or recent tax returns) and descriptive or promotional materials.

a.         Estimated Gross receipts for current fiscal period:            

b.         Estimated Cost of Goods Sold for current fiscal period:       

20. Have any of the individuals listed in question No.12 ever been the

      subject of disciplinary action by authorities as a result of their professional activities?           Yes    No        

            If YES, please explain:

21. Does any person 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?          Yes    No                                        

        If YES, please complete a Supplemental Claim Information form for each.

22. After inquiry have any claims been made against any proposed Insured(s) during the past three (3) years?     

        Yes    No                  

        If YES, please complete a supplemental Claims Information form for each claim.

        How many claims have been made in the last three (3) years?            

It is understood and agreed that with respect to questions 20, 21 and 22, that if such knowledge or information exists any claim or action arising there from is excluded from this proposed coverage.

Notice to New York applicants: any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

The Applicant hereby acknowledges that he/she/it is aware that the limit of liability shall be reduced, and may be completely exhausted, by the costs of legal defense and, in such event, the Insurer shall not be liable for the costs of legal defense or for the amount of any judgment or settlement to the extent that such exceeds the limit of liability.

The Applicant hereby further acknowledges that he/she/it is aware that legal defense costs that are incurred shall be applied against the deductible amount.

I HEREBY DECLARE that, after inquiry, the above statements and particulars are true and I have not suppressed or misstated any material fact and that I agree that this application shall be the basis of the contract with the Underwriters.

Person authorized to execute on behalf of the applicant:                                                 Date:   

This Application Form duly completed, together with any supplementary information, must be signed in ink by the person indicated. Signing of this form does not bind the Applicant or the Underwriters to complete the insurance. A copy of this application should be retained for your records.

Thank You for submitting this risk.
We will be back to you with a Quote as quick as we can.

---

Maintained by T-COM Associates, LTD.