| PLEASE ANSWER THESE QUESTIONS TO DECIDE IF
THIS PROGRAM IS RIGHT FOR YOU |
- Our firm is a consulting firm in private
practice.
|
Yes No |
- A principal in our firm is a licensed
architect or engineer.
|
Yes No |
- Please answer a) OR b)
- Our firm's total billings were under
$300,000 in our last fiscal year. OR
- Our firm was established in the last 12
months and anticipates fees under $300,000 for the next 3 years.
|
Yes No |
- Our fees emanating from services performed
in the USA or for USA projects (both this year and next) do not exceed 25%.
|
Yes No |
- Our fees emanating from USA?Overseas
combined (both this year and next) do not exceed 35%
|
Yes No |
- Our firm has been claims free for the past
five years.
|
Yes No |
- Less than 15% of our firm's services (both
this year and next) are rendered in connection with pollution and/or environment
services with no involvement in waste disposal services, petro chemical projects, remedial
services for known contaminated sites, underground storage tank services, building audits
or asbestos removal.
|
Yes No |
- Our firm is NOT a geotechnical, nuclear,
marine, design/build or design/manufacture firm.
|
Yes No |
- Our firm does not provide services to the
automotive, aircraft or railway industries.
|
Yes No |
- Our firm or any member of the firm has never
had a professional liability policy declined or non-renewed by an insurance company
in the past five years.
|
Yes No |
- Our firm is willing to use some sort of
written agreement on all projects.
|
Yes No |
If your responses to all of the statements
are "Yes" continue completing the quote.
If you answered "No" to any question, please contact us by email to receive
another quote form. instar@magma.ca |
| CONTACT INFORMATION |
| Surname: * |
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First Name: |
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| Address: |
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| Telephone: |
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| E-mail: * |
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| City: |
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| Province: * |
|
Postal
Code: |
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| FIRM INFORMATION |
| Firm Name: |
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| Predecessor Firm(s): |
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| No. of professional personnel: |
Firm
established in: |
yyyy |
| Billed
fees for the last 12 months (C$) |
Total
anticipated fees for next 12 months: (C$) |
Does
more than 25% of your firm's fees emanate from a single client: Yes
No
If yes, Provide client's name: |
The following is a description of our practices that best describes the
majority of our services:
|
| Our firm belongs to ACEC Other: |
|
| PRESENT
INSURANCE |
| We currently have professional liability coverage: Yes No |
| Our
insurance company is: |
| Our policy expires on: |
mm-dd-yyyy |
Are you aware of any alleged error, ommission or negligent act which might
result in a claim:
Yes
|
If
yes, provide details
|
| Please provide details of any claims, including date, amount, nature of
claim, amounts paid, reserves, and insurer. |
|
|
| LIMITS
OF LIABILITY |
|
Please indicate amount of liability required:
|
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