Technology Professional Liability Insurance Quote

Errors and Omissions Insurance Quote (E & O),
Professional Indemnity Insurance (PI Insurance)
Comprehensive General Liability Insurance (CGL),
ONLINE APPLICATION FOR TECHNOLOGY E&O PACKAGE POLICY.

You must disclose to the Insurer all information which is material to it in deciding whether to issue insurance cover to you, including any facts or conduct which might lead to a claim being made against you.

Failing to do so could affect your rights to indemnity.
If you would rather speak to a sales representative, please call us at 416-728-6806.
A Applicant Information:
1 Name of Organization:
2 Address 2 Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
3 Contact Person Name:
4 Telephone Number 4 Telephone Number - ### - ### ####
5 Email
6 Web Site
B Financial Information:
1 Current Annual Revenue:

Currency In Canadian Dollars only
2 Projected Annual Revenue:

Currency In Canadian Dollars only
3 How much of projected revenue is generated from the United States?

3 How much of projected revenue is generated from the United States? None Less Than 25% Between 26% to 50% 51% to 75% Over 76%

Currency In Canadian Dollars only
C Description of Business Activities
1. Please select your business activities and indicate below what percentage of your services fall into each: Total must be 100%

1. Please select your business activities and indicate below what percentage of your services fall into each: Total must be 100%
Application Service Provider Network / Communications Systems Prepackaged Software Gaming Developers Consulting/Training Security Software Custom Software Development Hardware Retail Sales Custom Programming Software Retail Sales Data Processing Facilities Management Hardware Assembly / Manufacturing Internet or Online Service Provider Wholesale / Distribution Repair / Maintenance of Equipment Online Auction or Gambling Site Web Hosting Social Networking Sites Web Development Telecommunications Website Graphic Designers Data Warehousing Business Software as Services Utility Computing System Design and/or Analysis Management Consulting IT Staffing and Recruiting Project Management Virtualization Other-provide detail in remarks
indicate percentage of each above activities and total must be equal to 100%

e.g System Design 40%
Business Software 60%
Total 100 correct example

e.g System Design 60%
Business Software 30%
Total 90% incorrect example
2 Please provide a short description of your operations (This decription will appear on the Declarations Page of your Policy):
3 Please indicate if any of the following are principal markets for your products or services:

3 Please indicate if any of the following are principal markets for your products or services:
Aerospace/Aviation Healthcare/Medical Oil and Gas Nuclear Military/Law enforcement Utilities None of the above
D Technology E&O and GL Questions
1 Please describe your company structure:
2 How long have you been in business for?
3 Have you changed your name or acquired any companies in the last 3 years
where you have 50% or greater ownership?
4 Total number of full-time employees:
E Claims Questions
1 Are you aware of any claim or demand for damages that has not yet been reported to your insurance company?
2 Within the past 5 years, have you had any claims?
3 Within the past 5 years, have you sued any customer for non-payment of fees; have had any complaints of being accused of a privacy violation; and/or have you experienced a network security breach that resulted from the unauthorized access of a third pa
4 Is any Insured aware of any fact, circumstance or situation involving the Company, the directors or officers of the Company which may give rise to a Claim under the Policy?
F Retroactive Date

Coverage will respond to incidents arising on or after the policy retroactive date and which are reported during the term of the policy.
1 Retroactive Date for Professional Services: 1 Retroactive Date for Professional Services: / MM / DD YYYY
2 Has the Insured maintained continuous coverage since this date?
G Property (Please complete required)
1 What is the building construction:
2 Is the building sprinklered:
3 Office Contents & Dollars valueâ€‚â€‚
(including any tenant improvement and electronic equipment)
4 Is the address entered in Section A your only location?

4 Is the address entered in Section A your only location? Yes No
If NO, please provide a separate sheet including additional location addresses, answers to the additional questions above in Section G.
Comments/Remarks
If possible, provide Resumes of persons performing professional activities: Copy of Standard client contract agreement, Claims information (if relevant):

Attach Files
Attach Files
Attach Files
The completion of this form is for quote purpose and does not provide any insurance coverage. We may require more information in order to provide a quote. This quote request contains some information about coverage offered but it does not contain all.

The completion of this form is for quote purpose and does not provide any insurance coverage. We may require more information in order to provide a quote. This quote request contains some information about coverage offered but it does not contain all. I agree

Technology Professional Liability Insurance Quote

Technology Professional Liability Insurance Quote

You must disclose to the Insurer all information which is material to it in deciding whether to issue insurance cover to you, including any facts or conduct which might lead to a claim being made against you.

If you would rather speak to a sales representative, please call us at 416-728-6806.

A Applicant Information:

B Financial Information:

C Description of Business Activities

D Technology E&O and GL Questions

E Claims Questions

F Retroactive Date

G Property (Please complete required)

If NO, please provide a separate sheet including additional location addresses, answers to the additional questions above in Section G.