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SSEECCTTIIOONN II:: BBAACCKKGGRROOUUNNDD IINNFFOORRMMAATTIIOONN
1. Name of Insured: __________________________________________________________________________________________________________
2. Address: __________________________________________________________________________________________________________________
City:____________________________________________ State: ______________________ Zip Code: _____________________________
Contact Name:_____________________________________________________________________________________________________________
Phone: _________________________ Date Established:__________________________(Resume required if less than 3 years in business)
Website: ______________________________________________________________ E-mail:____________________________________________
3. Is the Applicant controlled, owned, affiliated or associated with any other firm, corporation or company?
Yes No
If
YYeess
, please provide details: _______________________________________________________________________________________________
__________________________________________________________________________________________________________________________
4. Does the Applicant have any subsidiaries? Yes No
If
YYeess
, please list on a separate sheet and advise if coverage is to apply to them.
SSEECCTTIIOONN IIII:: OORRGGAANNIIZZAATTIIOONN OOPPEERRAATTIIOONNSS DDEETTAAIILLSS::
5.
Please describe in detail the professional services for which coverage is desired: _________________________________________________
__________________________________________________________________________________________________________________________
6. (a) List total gross receipts from activities in question #5
GGrroossss RReecceeiippttss
Last Year: $ ______________
Current Year (based on 12 months): $ ______________
Forecast for New Year: $ ______________
(b) Please indicate the percent of receipts listed in 6a from Operations outside of the U.S. and its territories: _________________________
(c) Did the Applicant have a positive net income in the past 12 months? Yes No
(d) Is the Applicant's overall net equity positive? Yes No
If
NNoo
, please advise net equity and steps being taken to correct the negative net equity. (on a separate sheet)
7. Is the applicant an Internet Service or Application Service Provider and/or does it provide
collocation services? Yes No
8. Is the applicant involved in online publishing, portal,and/or services as a web host, web search engine,
email hosting, chat room, online database, bulletin board, online sales or auctions? Yes No
If yes to 8, answer questions below and please describe on a separate sheet.
Does the applicant provide such services via their own server? Yes No
Does the applicant provide such services via third party vendor? Yes No
If yes to 3rd party services, what percentage of revenues? ___________________%
TTEECCHHNNOOLLOOGGYY PPRROOFFEESSSSIIOONNAALL LLIIAABBIILLIITTYY AAPPPPLLIICCAATTIIOONN
All questions must be answered and application must be signed by the applicant. This is an application for a claims made policy. Please read your policy
carefully.
TECH APP 11-05
page 1 of 5
Technology Professional Liability Product
Submit Application
99.. PPlleeaassee iinnddiiccaattee tthhee ppeerrcceennttaaggee ooff AApppplliiccaanntt''ss ggrroossss RReecceeiippttss ffrroomm tthhee llaasstt ffiissccaall ppeerriioodd iinnvvoollvviinngg::
Section A:
Section C:
Indicate the percentage of revenue from clients in the following industries:
____________% Residential _________% Retail _________% Government _________%Banking Investment
____________% Medical/Pharmaceutical _________% Entertainment _________% Legal _________% Other
10.
DDooeess aapppplliiccaanntt pprroovviiddee aannyy sseerrvviicceess,, wwhhiicchh eennaabbllee oorr aaffffeecctt aannyy ooff tthhee ffoolllloowwiinngg??
:
CAD/CAM design or control, robotics or process control of industrial equipment? Yes No ____%
Mechanical, electrical, chemical, civil or architectural design or engineering? Yes No ____%
Fund transfers or financial transactions or stock trading? Ye
s No ____%
Aircraft, air-ground equipment, military defense and/ or weaponry of any kind? Yes No ____%
Medical, dental or healthcare diagnosis, monitoring or treatment? Yes No ____%
Pharmaceutical formulation, production or prescriptions? Yes No ____%
911 or other emergency response and/or dispatch? Yes No ____%
Energy, power plant, utility or pollution monitoring, supply or distribution? Yes No ____%
Government regulation compliance? Yes No ____%
GPS, navigation systems (development, maintenance or support)? Yes No ____%
Lottery, sweepstakes, gaming, online casino, or other games of chance? Yes No ____%
Internet marketing, advertising? Yes No ____%
Please describe any percentages listed above: ________________________________________________________________________________
__________________________________________________________________________________________________________________________
11. Do you provide eCommerce services that promote the sale of goods and/or the ability to transfer funds
( i.e. online monetary exchange for goods and services, shopping cart, credit card processing)? Yes No
12. (a) Describe the 3 largest jobs or projects within the last three years:
Name of Client Services Provided Gross Billings
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
(b) If in business less than 1 year or a start up company, please describe the industries you are targeting for your products
and/or services? ___________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
TECH APP 11-05
page 2 of 5
Section B:
Technical Project Management ____%
Computer Security ____%
Network Security ____%
Packaged Software Development ____%
Hardware Manufacturing ____%
Wireless Installation/Configuration ____%
Hardware Sales ____%
Packaged Software Sales ____%
Online Marketing, Advertising ____%
Online Sales ____%
Other Services ____%
Web Site Development ____%
Training and Education ____%
Records Management/Retrieval ____%
Hardware Maintenance Services ____%
Network Cabling/Wiring ____%
Custom Software Development ____%
Data/Records Imaging, Warehousing or Storage ____%
Graphics ____%
Network Architecture/Design ____%
Packaged Software Installation/Configuration ____%
Network/Computer/Application Support ____%
System/Network Evaluation ____%
Equipment Evaluation and Selection ____%
Telecommunications ____%
13. (a) Is the Applicant a licensed professional (i.e. Lawyer, Accountant)? Yes No
If Yes, advise type of licensed professional: ___________________________________________________________________________________
(b) Number of principals, partners, officers and professional employees directly engaged in providing services to clients: _______________
(c) Number of non-professional employees (clerks, secretaries, etc.):_____________________________________________________________
14. Does the applicant utilize independent contractors? Yes No
If Yes, please answer the following question(s) regarding the use of independent contractors.
(1) How will the Applicant utilize each independent/subcontractor? _______________________________________________________________
(2) The total percent of Applicant's work done by independent/subcontractors: ____________________________________________________
(3) Does the Applicant require certificates of professional liability insurance from all independent contractors?
Yes No
(4) Do independent contractors work exclusively for the insured? Yes No
15. What do you see as your potential exposure to a professional liability claim? ______________________________________________________
__________________________________________________________________________________________________________________________
16. Does the Applicant use a standard written contract or letter of engagement with clients? Yes No
If yes In all Cases Sometimes
17. Do you utilize other company’s trademarks on your web site? Yes No
a. If “yes”, do you obtain written permission or are you authorized by contract to use the trademark(s)? Yes No
18. Do you sell or distribute products that you do not create? Yes No
a. If “yes”, do you receive revenues from products that you are not authorized to sell?
b. If “yes”, please attach explanation.
19. Do you purchase appropriate licenses for all software and hardware products utilized and/or require
customers to use only licensed products? Yes No
20. What do you see as your Intellectual Property exposures? ______________________________________________________________________
SSEECCTTIIOONN IIIIII:: CCLLAAIIMMSS IINNFFOORRMMAATTIIOONN
Do not complete this section if this is an application for a renewal policy at the same limit of liability with one of the United States Liability
Insurance Companies.
21. During the past 5 years, has any claim been made or suit brought against the Insured, its predecessor(s) in
business, or any of its present or former owners, partners, officers, directors, employees or independent contractors?
(If Yes, please forward a completed USLI supplemental claims application.) Ye
s No
22. Is any owner, partner, officer, director, employee or independent contractor aware of any circumstance, allegation,
contention or incident which may result in a claim being made against the Insured, its predecessor(s) in business,
or any of its present or former partners, owners, officers, directors, employees or independent contractors? Yes No
(If Yes, please please forward a completed USLI supplemental claims application.)
SSEECCTTIIOONN IIVV:: PPRROOFFEESSSSIIOONNAALL LLIIAABBIILLIITTYY IINNSSUURRAANNCCEE CCOOVVEERRAAGGEE
23. Has any policy of or application for professional liability insurance on your behalf or on the behalf of any of your principals,
officers, employees, independent contractors or on behalf of any predecessor(s) in business ever been declined,
cancelled or non-renewal refused? Yes No
If Yes, advise details: _______________________________________________________________________________________________________
24 . Is similar professional liability insurance currently in force? Yes No
Name of Carrier, Limit, Retro Active date,Deductible, Premium, Policy Period
__________________________________________________________________________________________________________________________
Length of time coverage has continuously been in force: ________________________________________________________________________
page 3 of 5
TECH APP 11-05
GGEENNEERRAALL LLIIAABBIILLIITTYY IINNSSUURRAANNCCEE::
25. Does the Applicant currently have General Liability Insurance? Yes No
If yes, please advise the following:
Name of Carrier ___________________________________________________________________________________________________________
Limit______________________________________________________________________________________________________________________
Premium __________________________________________________________________________________________________________________
Expiration Date ____________________________________________________________________________________________________________
26. During the last 5 years, has any claim been made or suit been brought against the Applicant? Yes No
(If yes, please provide details on a separate supplemental claim application.)
27. Is the Applicant involved in the installation of hardware, electrical work, wiring and/or cable installation of the items for
which they are providing consultation services (including work done by Independent Contractors on behalf
of the Applicant)? Yes No
28. Additional Insured(s) to be included (List name, address and relationship to Applicant): _____________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
PPRROOPPEERRTTYY IINNSSUURRAANNCCEE::
29. Personal Property Limit: ____________________________________________________________________________________________________
30. Building Construction (please check one):
Frame - Bldg. Is made from a wood frame (2x4's/veneers).
Joisted Masonry - Outside walls are constructed with bricks/cinder blocks. Roof is made of wood.
Masonry Non-Combustible - Same as Joisted Masonry, except roof is steel.
Fire Resistive - Structural steel framing, reinforced concrete outside/load bearing walls.
31. Property Protection Class (1-10): _________________________________________ Zip Code: ______________________________________
32. (a). Aluminum Wiring: Yes No
(b). Functioning Fire/Smoke Alarms: Yes No
(c).Burglar Alarms: Yes No
33. Is the electrical system connected to circuit breakers?: Yes No
34. During the last 5 years, has any property claim been made or suit been brought against the applicant?
Ye
s No
SSEECCTTIIOONN VV:: RREEQQUUIIRREEDD IINNFFOORRMMAATTIIOONN
A. United States Liability Insurance Group Application.
B. Resume.
MMiinnnneessoottaa NNoottiiccee::
The clause “and/or authorization or agreement to bind the insurance” is replaced with “authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of the
insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when he contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.”
VViirrggiinniiaa NNoottiiccee::
You have an option to purchase a separate limit of liability for the extension period, Policy common conditions VII. If you do
not elect this option, the limit of liability for the extension period shall be part of the and not in addition to limit specified in the declarations.
Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any affidavit made
before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was
material to the risk when assumed and was untrue.
NNeeww YYoorrkk DDiisscclloossuurree NNoottiiccee::
TThhiiss ppoolliiccyy iiss wwrriitttteenn oonn aa ccllaaiimmss mmaaddee bbaassiiss aanndd sshhaallll pprroovviiddee nnoo ccoovveerraaggee ffoorr ccllaaiimmss aarriissiinngg oouutt ooff iinncciiddeennttss,, ooccccuurrrreenncc