Technology Professional Liability

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Name of Applicant* This field is required.Company's Name
2
Contact* This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
Phone Number
Area Code
Phone Number
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Entity Type:* This field is required.
Corporation
Individual
Partnership
Corporation
LLC
Joint Venture
Other
7
Description of Operations* This field is required.Please describe in detail the operations for which coverage is desired
Huge
Large
Normal
Small
Ok
Ok
8
What does your business do? Please check each one that applies. Select “Other” if your business description is not listed and write a short description of the services you provide.* This field is required.
Cloud providers/application service providers/software as a service What percentage of receipts are derived from this? __________ %
Consulting/training/project management/staffi ng
Data or records storage/retrieval/back-up What percentage of receipts are derived from remote data back-up? __________ %
Database administration
Hardware evaluation/selection/maintenance
Hardware manufacturing What percentage of receipts are derived from this? ___________
Help desk
Internet service provider, search engine or online publishing/sales
Network or computer security. What percentage of receipts are derived from this? ___________
Software development/installation/sales. If developing packaged software, please provide number of licenses __________
Systems, network, or audio visual evaluation/design/cabling/support
Web design/development/hosting or search engine optimization
Other services not listed:___________________________________________________
9
Current annual domestic revenue (United States, its territories and Canada)* This field is required.
10
Current annual foreign revenue (outside the United States, its territories and Canada)* This field is required.
11
Principals, partners, officers: providing professional services:* This field is required.
providing services
not providing services
# of Principals, partners, officers:
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Row 0, Column 1
# of Principals, partners, officers:
providing services
Row 0, Column 0
not providing services
Row 0, Column 1
12
Employees providing professional services (paid on W2)* This field is required.
Full-time:
Part-time:
Employees providing professional services
Row 0, Column 0
Row 0, Column 1
Employees providing professional services
Full-time:
Row 0, Column 0
Part-time:
Row 0, Column 1
13
Independent Contractors (paid on 1099):* This field is required.
exclusively working for applicant:
all other:
Employees providing professional services
Row 0, Column 0
Row 0, Column 1
Employees providing professional services
exclusively working for applicant:
Row 0, Column 0
all other:
Row 0, Column 1
14
What is the earliest date of continuous errors and omissions liability coverage?* This field is required.
15
Have you initiated litigation against any of your clients in the past five years? (If “Yes,” advise how many times you have initiated litigation in the past five years along with details for each.)* This field is required.
YESNO
16
For errors and omissions, general liability and/or property, in the last five 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 provide details on a separate supplemental claim application.* This field is required.
YESNO
17
Is any owner, partner, 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 or independent contractors? If “Yes,” please provide details on a separate supplemental claim application* This field is required.
YESNO
18
Please indicate the percentage of your services that affect or enable any of the following:* This field is required.
%
Credit card or other payment card transactions including POS systems
Row 0, Column 0
Fund transfers, financial transactions, equity trading or loan fulfillment
Row 1, Column 0
Video game development (provide title and style of games)
Row 2, Column 0
• Lottery, sweepstakes, gaming, online casino or other games of chance:
Row 3, Column 0
Firmware or embedded software
Row 4, Column 0
Mechanical, electrical, chemical, civil or architectural design or engineering:
Row 5, Column 0
Robotics or process control of industrial equipment including HVAC systems or CAD/CAM design or control
Row 6, Column 0
Physical security system installation or monitoring (including but not limited to burglar/fire alarms and camera systems):
Row 7, Column 0
Global Positioning System (GPS), Geographic Information System (GIS), navigation systems development, maintenance or support
Row 8, Column 0
Aircraft, air-ground equipment, military defense and/or weaponry of any kind including classified information:
Row 9, Column 0
Medical, dental or healthcare diagnosis, monitoring or treatment
Row 10, Column 0
Management or use of health or medical information including electronic records
Row 11, Column 0
Pharmaceutical formulation, production or prescriptions including clinical data:
Row 12, Column 0
911 or other emergency response and/or dispatch:
Row 13, Column 0
Energy, power plant, utility or pollution monitoring, supply or distribution:
Row 14, Column 0
Credit card or other payment card transactions including POS systems
Fund transfers, financial transactions, equity trading or loan fulfillment
Video game development (provide title and style of games)
• Lottery, sweepstakes, gaming, online casino or other games of chance:
Firmware or embedded software
Mechanical, electrical, chemical, civil or architectural design or engineering:
Robotics or process control of industrial equipment including HVAC systems or CAD/CAM design or control
Physical security system installation or monitoring (including but not limited to burglar/fire alarms and camera systems):
Global Positioning System (GPS), Geographic Information System (GIS), navigation systems development, maintenance or support
Aircraft, air-ground equipment, military defense and/or weaponry of any kind including classified information:
Medical, dental or healthcare diagnosis, monitoring or treatment
Management or use of health or medical information including electronic records
Pharmaceutical formulation, production or prescriptions including clinical data:
911 or other emergency response and/or dispatch:
Energy, power plant, utility or pollution monitoring, supply or distribution:
%
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%
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Does the applicant provide government regulation compliance services? If “Yes,” please list applicable regulations* This field is required.
YESNO
20
Does the Applicant provide services to hospitals?* This field is required.
YESNO
21
Does the Applicant maintain personal information* on individuals other than Applicant’s employees?* This field is required.
YESNO
22
Please select the security measures below used by Applicant to protect personal information. By signing this application, the Applicant represents that (1) the security measures selected below are fully operational and functional as of the date this Application Is signed and (2) the Applicant will maintain the operation and functionality of the security measures selected below throughout the terms) of the policy and any renewals thereof* This field is required.
Encryption of all personal information on your network
Encryption of e-mail with personal information
Encryption of all mobile devices, laptops and portable media which contain
personal information
Encryption of Back-up Storage Devices
Commercially available fi rewall protection systems
Anti-virus software on all internet accessible devices, mail servers, desktops,
and laptops
Intrusion detection software
Regular implementation of hardware and software security updates and
patches
Server equipment physically located in secured access area
Asset management program or access lists to track permissions for hardware
and software
Regular backup of all computers, including all mobile devices, laptops and
portable media, to a server
Written security policy addressing the use, storage and disclosure of personal
information reviewed regularly by an attorney and signed by all employees
Procedures to regularly purge data containing personal information
from internet-connected systems
Secure password protection for all employees including:
Contains non-alphanumeric characters
At least 8 characters long
Does not contain login name or user’s birthdate
Contains a variation of capital and lower case letters
Deactivation of passwords of terminated employees
Permanent removal of personal information no longer required from hard drives and storage media prior to discard or sale
Paper records shredded prior to disposal
Require third party providers to have minimum security measures for the use, storage and disclosure of personal information shared between them and the applican
Contracts with third party providers provide for indemnifi cation of the Applicant for the unauthorized use or disclosure of stored
23
Have any regulatory, governmental or administrative action(s) been brought against the Applicant involving the use or disclosure of personal information?* This field is required.
YESNO
24
Is the applicant aware of any data breach that has or may result in unauthorized use or disclosure of personal* This field is required.
YESNO
25
Has the Applicant received or is it aware of any complaint, notice or claim involving a data breach resulting in the unauthorized use or disclosure of personal information held by the Applicant or personal information held by a client of the Applicant?* This field is required.
YESNO
26
If the applicant provides services that are involved in credit card or other payment card transactions, is the applicant compliant with Payment Card Industry Data Security Standards (PCI DSS): If “No”, please explain:* This field is required.
YESNO
27
Does organization have a commercial automobile policy in place?* This field is required.
YESNO
28
Does organization own any autos or lease any autos in excess of 30 days?* This field is required.
YESNO
29
Do you provide any offsite “at home” or “at office” computer repair or other related computer services, e.g. “Geek Squad”* This field is required.
YESNO
30
Maximum number of days in a given year the applicant, including their partners and their employees rents a vehicle for business purposes.* This field is required.
YESNO
31
Please indicate the number of employees using their personal automobiles for business purposes, ie. going to clients offices* This field is required.
YESNO
32
Do any of these employees visit more than one client per day on a regular basis? If “Yes,” please explain.* This field is required.
YESNO
33
Business personal property limit* This field is required.
Business personal property limit
Business personal property limit
$
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$
Business personal property limit
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Business personal property limit
Row 0, Column 1
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Submit ApplicationI 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.
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