Computer Consultants Professional Liability Insurance

Basic Information

 

1. Name of Applicant:

 

 

2. Address:

3. Phone:

Fax:

E-mail:

Area of Practice

4. Please describe in detail the nature and types of professional services the Applicant is engaged:


4a. Indicate activities which apply to your business and the % of expected revenue and other information requested during the next 12 months: (Please check all that apply.)

a. Data Processing and Entry % k. Content Provider for Web Page/Forum %
b. Custom Software Development % l. Web Page %
c. Packaged Software Development % m. Commercial On-Line Services %
d. Consulting on Hardware/Software System design/purchase % n. Forum/Content Channel %
e. Systems Installation % o. Electronic BBS %
f. Systems Maintenance % p. FTP Site %
g. Computer Related Training % q. Internet Access Provider %
h. Web Page Development % r. Forum Manager %
i. Web Page Maintenance/Updates % s. Game Developer %
j. Hosting Web Pages % t. Other %

TOTAL

%
Experience and Personnel


5. Date Established:


6. Are they significant changes in the nature of size of the Applicant's business anticipated over the next 12 months? Or have there been any such changes in the past 12 months?
If yes, Please explain:


7. Total Number of staff:


8. Please provide the following:
Name of Principals & Qualified Employees Professional Qualifications/Designations Number of Years in Practice

Number of years with Applicant

Please provide brief resumes of the Principals:

Billing Details and Breakdown

9. Gross billings:
Last year (est):
This Year:
Next prior:

10. Please indicate the Applicant's five larges jobs/projects during the past three years:

Client

Service

Applicant's Fee


11. Please indicate the major software applications and receipts attributable:
Nature Market Home Use % Commercial Use % Total Receipts %
a. Administrative (sales data lists, etc) % % %
b. Accounting (payroll, receivables, payables % % %
c. Financial (savings, checking loan, dividend accounts) % % %
d. Inventory Control % % %
e. Scientific % % %
f. Graphics % % %
g. Architectural (Model Building projection) % % %
h. CAD/CAM: Manufacturing/Engineering tools % % %
i. CASE: Application development tools % % %
j. Communications: Utilities/Info Services % % %
k. Fund Transfer % % %
l. Medical % % %
m. Educational % % %
n. Facilities Management % % %
o. Office Automation % % %
p. Database Management Systems % % %
q. LAN/Network % % %
r. Imaging % % %
s. Gatekeeper % % %
t. Other (please explain) % % %


12. Indicate the market(s) for your products/services



Aerospace
Receipts %

%

Communications/Transportation %
Construction/Mining/Agriculture %
Education %
Financial Institutions %
Government  (military) %
Government (non military) %
Health Care/Medical Services %
Home Use %
Manufacturing/Industrial %
Trade: Retail/Wholesale %
Other %
Risk Management

13. Do you have a policy for removing controversial material: (libelous, slanderous, etc) from your On-line Service?


If yes, Please explain:

14. How often is libelous or slanderous information removed from your On-line Service per month?
15. Do you have a policy for removing infringing material (copyright, trademark, etc) from your On-line Service?
If yes, Please explain:

16. Does the Applicant use a written contract (please provide percentages):
If not always, please explain how the scope services to be provided is agreed:

 

17. Does any director, officer, employee or partner of the Applicant serve on the board of directors of any client of the Applicant? If yes, Please explain:

 

18. Does the Applicant sub-contract work to others: If yes, please explain and include the nature of indemnities, hold harmless agreements, etc::

 

Insurance Details
19. Has any errors and omissions or professional liability insurance ever been declined or cancelled? If yes, Please explain:

20. Is there any errors and omissions or professional liability insurance in favor of the Applicant currently in force?  If yes, please indicate errors and omissions insurance carried for each each of the past three years:

Carrier

From
(mm/yy)
To
(mm/yy)
Limit Deductible Premium

Retrodate

21. Has the Applicant or any director, officer, employee or partner been subject to disciplinary action as a result of professional activities?
If yes, Please explain:

 

22. Is the Applicant aware of any errors, omissions or claims (including any circumstances reported to previous insurers which have not developed into claims)
If yes, Please complete Attachment A

 

23. Has the Applicant been a party to any lawsuit other legal proceeding within the past five years?
If yes, please provide (on Attachment A) a description which includes the venue  of the action, the parties, the amount at dispute, the nature of the claim(s), the status of the action(s) and how the action(s) was resolved as to the applicant, including all costs incurred; including defense expenses.

 

24. The basic policy for which you have applied will not cover acts, errors or omissions which took place prior to the inception date of the policy.  If you desire a quote for these prior acts, please enter the date from which you want prior acts covered .  (Note that coverage does not apply to known or expected claims or those which any insured should have foreseen).

 

Attachment A

Please complete this form if the Applicant is aware of any claims as indicated in Question 23 & 24 of the Application Form (including any circumstances reported to previous insurers which have not developed into claims) during the last ten years.
1. Name of Applicant:
2. Name of Member of Staff involved in claim:
3. Name of (potential) claimant:
4. Date of incident:
    Date of claim made:
5. Under which policy was the claim made?  
    Carrier:
    Policy No.:
6. Status of Claim:      

If closed, please indicate Total Loss Paid:
If Open, please complete questions 7, 8, 9, and 10
7. Total defense costs and expenses to date:
8. Damages or other relief sought by the claimant(s):
9. Insurers loss reserve:
10. Please provide the following details:
i) the specific act, error or omission upon which the claimant bases the claim. 
ii) a brief description of the claim
iii) details of the current status and proposed strategy for handling the claim.

This document is a non-binding indication question sheet and is subject to receipt of a fully completed application and supporting documents prior to firm quotations being rendered by the company.  Upon review of these documents, the company reserves the right to change the terms indicated via this questionnaire or decline to render terms for this coverage.