What is your first name? *
What is your last name? *
What is your email address? *
What is your phone number? *
What is the name of the applicant? (I.e. Business name) *
What is the applicant’s mailing address? *
Is the location address different than the mailing address? *
Please enter the location address of the applicant. *
What year was the applicant’s business established? *
What is the legal entity type the applicant operates under?
What is the other legal entity type the applicant operates under?
What date do you want this insurance to be effective? *
MM slash DD slash YYYY
What is the applicant's website address? *
Nature of Operations
Please describe in detail the professional activities for which coverage is desired:
Is the applicant engaged in any business or profession other than as a described in the previous question?
Please describe the other business or profession the applicant is engaged in.
Please provide the total gross revenues for the years indicated which are derived from the applicant’s and any Subsidiaries professional services:
Please check the box next to the sections that apply to the applicant's business. (Select all that apply.) *
Please provide total gross revenue of any Other service.
Please select the industry type(s) the applicant does business with. (Select all that apply)
Estimate the total percentage of revenue that is derived from the Aerospace & Defense industry.
Estimate the total percentage of revenue that is derived from the Chemical industry.
Estimate the total percentage of revenue that is derived from the Construction industry.
Estimate the total percentage of revenue that is derived from the Engineering industry.
Estimate the total percentage of revenue that is derived from the Consumer industry.
Estimate the total percentage of revenue that is derived from the Electrical Equipment industry.
Estimate the total percentage of revenue that is derived from the Energy Equipment & Services industry.
Estimate the total percentage of revenue that is derived from the Financial Services industry.
Estimate the total percentage of revenue that is derived from the Government Services industry.
Estimate the total percentage of revenue that is derived from the Healthcare industry.
Estimate the total percentage of revenue that is derived from the Information Technology industry.
Estimate the total percentage of revenue that is derived from the Manufacturing industry.
Estimate the total percentage of revenue that is derived from the Media industry.
Estimate the total percentage of revenue that is derived from the Telecommunications industry.
Estimate the total percentage of revenue that is derived from the Transportation industry.
Estimate the total percentage of revenue that is derived from the Oil, Gas, & Utilities industry.
Estimate the total percentage of revenue that is derived from the Retail industry.
Estimate the total percentage of revenue that is derived from Other services.
Please describe the other industry(s) the applicant does business with.
Does the applicant provide any services over the internet?
Please describe the services provided over the internet.
What percentage of the applicant’s revenues are generated through the internet?
Does the applicant derive more than 10% of revenues from state county or local government?
Please provide a description of the business conducted with state, county, or local government.
Coverage Selection
Please select the coverages for which you are requesting a proposal. (Select all that apply) *
Organizational Structure
Is the applicant's business controlled, owned or associated with any other firm, corporation or company?
Please provide an explanation of the applicant’s relationship with the other firm, corporation or company.
Are any of the previously described business activities provided to such business enterprise?
Does any person acting on behalf of the applicant also act as a director officer or other executive for any client organization?
Employees
What is the total number of employees the applicant has?
How many principals, partners, officers and professional employees directly engage in providing services to clients?
How many partners/principles/key employees are there? *
What is the first Partner/Principle/Key Employee’s full name? *
What is their title? *
What professional designations/qualifications do they have? *
What is the date they qualified as a partner/principle? *
MM slash DD slash YYYY
How long have they been in practice? *
What is the second Partner/Principle/Key Employee’s full name?
What is their title?
What professional designations/qualifications do they have?
What is the date they qualified as a partner/principle?
MM slash DD slash YYYY
How long have they been in practice?
What is the third Partner/Principle/Key Employee’s full name?
What is their title?
What professional designations/qualifications do they have?
What is the date they qualified as a partner/principle?
MM slash DD slash YYYY
How long have they been in practice?
What is the fourth Partner/Principle/Key Employee’s full name?
What is their title?
What professional designations/qualifications do they have?
What is the date they qualified as a partner/principle?
MM slash DD slash YYYY
How long have they been in practice?
Please upload a file containing the partner/principle/key employee's full names, if convenient.
How many non-professional employees (clerks, secretaries, etc.) are there?
Please list all of the professional associations to which the Applicant belongs:
Media Liability
Select the type of media services the applicant provides. (Select all the apply) *
Multimedia
Please check the box next to the multimedia service(s) for which the applicant is seeking coverage.
What percentage of the applicant’s gross revenue is derived from Advertising Placement services?
What percentage of the applicant’s gross revenue is derived from Branding services?
What percentage of the applicant’s gross revenue is derived from Contest/Promotion/Coupons services?
What percentage of the applicant’s gross revenue is derived from Catalog/Direct Mail services?
What percentage of the applicant’s gross revenue is derived from Literary Agent services?
What percentage of the applicant’s gross revenue is derived from Market Research services?
What percentage of the applicant’s gross revenue is derived from Music Composition services?
What percentage of the applicant’s gross revenue is derived from Merchandising services?
What percentage of the applicant’s gross revenue is derived from Package Design services?
What percentage of the applicant’s gross revenue is derived from Product Design services?
What percentage of the applicant’s gross revenue is derived from Product Testing services?
What percentage of the applicant’s gross revenue is derived from Printing services?
What percentage of the applicant’s gross revenue is derived from Public Relations services?
What percentage of the applicant’s gross revenue is derived from Trademark Design services?
What percentage of the applicant’s gross revenue is derived from Video/Film Production services?
What percentage of the applicant’s gross revenue is derived from Website Design services?
What percentage of the applicant’s gross revenue is derived from the Other services?
What percent of the applicant’s gross revenues can be considered pass thru costs?
Does the applicant or any subsidiaries create any media content or perform any multimedia services for entities which own the applicant or for entities that the applicant owns, controls or is affiliated with?
Newspaper/Magazine/Book Publishers Liability
Is the applicant seeking Newspaper/Magazine/Book Publishers Liability coverage?
Please enter each of the publications the applicant and all subsidiaries wish to have coverage for. (Click the circle with the plus sign to add a publication.) *
Broadcasters Liability
Is the applicant and all subsidiaries seeking Broadcasters Liability coverage.
Please enter each of the Radio/Television Stations that are owned or operated by the applicant or subsidiaries.
Contracted work
Does the applicant or any subsidiary use subcontractors or any independent contractors such as freelance photographers, models, writers, composers, artists, musicians or website developers?
Does the applicant and all subsidiaries obtain written releases with respect to the creative material or talent that they provide?
Contractual/Quality Control Procedures
Does the applicant and all subsidiaries use a written contract or agreement with all clients?
Does anyone other than a principle have the authority to amend the standard contract?
Please enter the position of the individual(s) who have the authority to amend the standard contact.
What percentage of the time does the applicant use their standard contract vs the client’s contract.
Please select the sections included in the standard contract: (Select all that apply)
Please upload a sample of the contract, if convenient.
Please upload a resume or biography for the key principals if the applicant has been in business less than three years.
Please upload a sample agreement or written release used with Authors Freelances Distributors Advertisers etc.
Technology and Telecommunications
Please select the service(s) your Technology and/or Telecommunications company offers. (Select all that apply)
Estimate the total percentage of revenue that is derived from Application Services Provider services.
Estimate the total percentage of revenue that is derived from Cellular Company services.
Estimate the total percentage of revenue that is derived from Computer Programming services.
Estimate the total percentage of revenue that is derived from Computer/Network services.
Estimate the total percentage of revenue that is derived from Integration services.
Estimate the total percentage of revenue that is derived from Computer Maintenance services.
Estimate the total percentage of revenue that is derived from Computer Hardware services.
Estimate the total percentage of revenue that is derived from Manufacturing services.
Estimate the total percentage of revenue that is derived from Computer Training/Education services.
Estimate the total percentage of revenue that is derived from Data Center services.
Estimate the total percentage of revenue that is derived from E-mail Service services.
Estimate the total percentage of revenue that is derived from Electronic Component Manufacturing services.
Estimate the total percentage of revenue that is derived from IT Consulting/Staffing services.
Estimate the total percentage of revenue that is derived from Internet Services Provider services.
Estimate the total percentage of revenue that is derived from Managed IT services.
Estimate the total percentage of revenue that is derived from Reseller of Computer Hardware & Software services.
Estimate the total percentage of revenue that is derived from Security Consulting/Products services.
Estimate the total percentage of revenue that is derived from Software Developer services.
Estimate the total percentage of revenue that is derived from Telecom Consulting services.
Estimate the total percentage of revenue that is derived from Telecom Company services.
Estimate the total percentage of revenue that is derived from Video Conferencing services.
Estimate the total percentage of revenue that is derived from Voice Over Internet Protocol Services (VOIP).
Estimate the total percentage of revenue that is derived from Wireless Communication services.
Estimate the total percentage of revenue that is derived from Website Developer services.
Estimate the total percentage of revenue that is derived from Website Hosting services.
Please describe the other service(s) the applicant provides.
Does the applicant or any subsidiaries perform any services to entities which own the applicant or for entities the applicant owns, controls or is affiliated with?
Please provide an explanation
Does the applicant or any subsidiary use subcontractor or any independent contractors to provide any professional services?
What is the percentage of revenues that comes from contracted services?
Contractual Procedures
Does the applicant and all subsidiaries use a written contract service agreement or invoice with clients?
Does anyone other than a principle have the authority to amend the standard contract?
Please enter the position of the individual(s) who have the authority to amend the standard contact.
Please select the sections included in the standard contract: (Select all that apply)
Please upload a sample of the contract.
Quality Control
Indicate which of the following quality control procedures are in place. (Select all that apply)
Please describe the other quality control procedures that are in place.
Indicate which of the following quality control procedures you have in place to protect your facilities, networks, and servers. (Select all that apply)
Network Security & Privacy Section
Please check the box next to the IT policy or procedure the Applicant and all Subsidiaries have in place. (Select all that apply)
Please check the box next to each information type the Applicant has within its care custody or control. (Select all that apply)
Please describe the other information types the Applicant has within its control.
How many individual records are within the Applicant’s care custody and control? (Approximately)
Does the Applicant outsource and of its IT/Data management activities or entrust 3rd parties with sensitive information?
Please check the box next to the item(s) that are applicable to the 3rd parties that the Applicant entrusts sensitive information to.
Does the applicant and all subsidiaries use software and hardware that is supported by the manufacturer?
Does the applicant and all subsidiaries employ a Chief Information Security Officer IT Manager or Privacy Officer?
Please enter the position responsible for Information Security & Privacy within your company
Does the applicant and all subsidiaries implement virus controls malware/spyware detection firewall and filtering on all systems?
Does the applicant and all subsidiaries check for security patches to their systems at least weekly and implement them within 30 days?
Does the applicant and all subsidiaries replace factory default settings to ensure their information security systems are securely configured?
Does the applicant and all subsidiaries have a way to detect unauthorized access or attempts to access sensitive information?
Does the applicant and all subsidiaries allow remote access to their network?
Does the applicant and all subsidiaries use industry standard VPCN, SSL, VPN or equivalent technology?
Does the applicant and all subsidiaries utilize two-factor authentication?
Does the applicant and all subsidiaries control and track all changes to their network(s) so they remain secure?
Does the applicant and all subsidiaries re-assess security threats and upgrade their risk controls in response at least yearly?
Does the applicant and all subsidiaries limit access to data on a need-to-know basis?
Does the applicant and all subsidiaries allow sensitive data to be stored on laptops and mobile devices?
Does the applicant and all subsidiaries ensure such devices utilize full disk encryption?
Does the applicant and all subsidiaries allow employees to store or access sensitive data on their own personal devices?
Does the applicant and all subsidiaries ensure such devices utilize full disk encryption?
Does the applicant and all subsidiaries conduct desktop drill/exercises to test their incident response plan?
Does the applicant and all subsidiaries securely dispose of paper or electronic data when no longer needed?
Does the applicant and all subsidiaries terminate employee access when an individual leaves the company?
In the event of a virus malware attack or computer attack what is the recovery time objective for critical business operations?
Does the applicant and all subsidiaries display publish or disseminate content?
Does the applicant and all subsidiaries have procedures in place to screen material for copyright and trademark infringement including invasion of privacy?
Does the applicant accept credit card transactions?
How many credit card transactions are there per year?
What percentage of the transactions use EMV (Chip-card technology)?
Is the applicant PCI compliant?
What is the applicant's method of achieving PCI compliance?
Does the credit card data go direct to a 3rd party payment processor?
Please check all that apply to the handling of credit card data in the applicant’s network.
Please provide details about any question answered with a “No” response.
Employment Practices Information
How many full time employees did the business have in the current and previous years?
How many part time employees did the business have in the current and previous years? (Include leased and seasonal)
How many employees were located in California during the current and previous years?
How many volunteers did the business have in the current and previous years?
Does the business have written procedures in place regarding equal opportunity employment?
Please provide a full explanation.
Does the business have written procedures in place regarding anti-discrimination?
Please provide a full explanation.
Does the business have written procedures in place regarding anti-sexual harassment?
Please provide a full explanation.
During the past three years, has the business or any applicant in any capacity, been involved in an EEOC, NLRB or other similar administrative proceeding?
Please provide a full explanation.
During the past three years, has the business or any applicant in any capacity, been involved in an employment-related civil suit?
Please provide a full explanation.
What was the annual employee turnover percentage rate for last year? (Past Year)
What was the annual employee turnover percentage rate for the year before last? (1 Year Previous)
What was the annual employee turnover percentage rate three years ago? (2 Years Previous)
How many involuntary terminations have occurred in the last year? (Past Year)
How many involuntary terminations have occurred in the year before last? (1 Year Previous)
Optional Third-Party Information
Applicant: Please complete this section only if requesting Employment Practices Liability coverage.
Does the business have established written polices or procedures outlining employee conduct when dealing with third parties, including non-discrimination and non-harassment statements?
Does the business have established written polices or procedures for responding to complaints of harassment, discrimination or civil rights violations from third parties?
What percentage of the business's employees and volunteers have direct contact with the general public?
Has the business ever had any action or civil suit brought against it by a customer, client or third party alleging harassment, discrimination, or civil rights violations?
Please provide a full explanation and details.
Fiduciary Information
Please complete the following information regarding the business's employee benefits plan(s). (Click the circle to the right of the table to add additional plans.)
- *Types of Plans:
Defined Contribution Plan =DCP, Defined Benefit Plan = DBP,
Employee Stock Ownership Plan = ESOP,
Excess Benefit Plan or Top Hat Plan = EBP.
Does the business handle any investment decisions in-house?
Please provide an explanation.
Does each of the business's employee benefit plans conform to the standards of eligibility, participation, vesting and other provisions or ERISA?
Please provide an explanation.
Has any fiduciary been accused of, found guilty of, or held liable for a breach or trust?
Please provide an explanation.
Has any fiduciary been convicted of criminal conduct?
Please provide an explanation.
Has there been any assessment of fees, fines or penalties against any of the business's employee benefit plans under any voluntary compliance resolution program or similar voluntary settlement program administered by the IRS, DOL or other government authority?
Please provide an explanation.
Crime Information
Does the business maintain a list of authorized vendors?
Does the business verify invoices against a corresponding purchase order, receiving report, and the authorized master vendor list prior to issuing payment?
Does the business allow the employees who reconcile the monthly bank statements to also sign checks or handle deposits?
Does the applicant perform pre-employment reference checks for all its potential employees?
Please provide an explanation.
Has the business had any occurrences of employee theft, burglary, robbery, forgery, computer fraud or other crime in the last five years?
Please list all employee theft, burglary, robbery, forgery, computer fraud or other crime losses discovered by the business in the past five years. Itemize each loss separately; including date of loss, description and total amount.
Kidnap, Ransom and Extortion Information
Please complete the following information regarding the foreign travel of the business's employees. (Click the "plus" circle to the right of the table to add additional countries.)
Previous Client Engagements
Please enter the requested information about the applicant's five (5) largest clients /projects in the previous three (3) years.
What is the first client/project name?
What was the nature of the services performed?
What was the contract value($)?
How long did the project take to complete? (Years/Months)
What is the second client/project name?
What was the nature of the services performed?
What was the contract value($)?
How long did the project take to complete? (Years/Months)
What is the third client/project name?
What was the nature of the services performed
What was the contract value($)?
How long did the project take to complete? (Years/Months)
What is the fourth client/project name?
What was the nature of the services performed
What was the contract value($)?
How long did the project take to complete? (Years/Months)
What is the fifth client/project name?
What was the nature of the services performed
What was the contract value($)?
How long did the project take to complete? (Years/Months)
Subcontractors
Does the applicant’s business involve subcontracting any work to others?
How many independent contractors/subcontractors does the applicant hire?
Do the Independent Contractors/Subcontractors provide the same services as the applicant?
What percentage of the applicant’s revenues come from subcontracting work to others?
Does the application require evidence of professional liability insurance from subcontractors?
Does the applicant always use a written contract upon engagement of a contractor?
Please upload a sample contract.
Subsidiary/Joint Venture Information
Does the applicant own any subsidiaries or have any 50% or more owned joint ventures under management control?
What is the name of the subsidiary?
What percentage of the subsidiary does the applicant own/control?
What year did the subsidiary relationship begin?
Please provide a brief description of the subsidiary's operations.
Please enter the business entity type the subsidiary operates under.
Does the applicant own a second subsidiary or a 50% or more owned joint venture under management control?
What is the name of the second subsidiary?
What percentage of the second subsidiary does the applicant own/control?
What year did the second subsidiary relationship begin?
Please provide a brief description of the second subsidiary's operations.
Please enter the business entity type the second subsidiary operates under.
In the next 12 months (or during the past 24 months) is the applicant contemplating (or has the applicant completed or been in the process of completing) any actual or proposed merger, acquisition, or divestiture?
Please provide an explanation with specifics.
In the next 12 months (or during the past 24 months) is the applicant contemplating (or has the applicant completed or been in the process of completing) any creation of a new business subsidiary or division?
Please provide an explanation with specifics.
In the next 12 months (or during the past 24 months) is the applicant contemplating (or has the applicant completed or been in the process of completing) any reorganization or arrangement with creditors under federal or state law?
Please provide an explanation with specifics.
In the next 12 months (or during the past 24 months) is the applicant contemplating (or has the applicant completed or been in the process of completing) any branch location office closing consolidating or layoffs?
Please provide an explanation with specifics.
Current Errors & Omissions Coverage
Does the applicant currently purchase professional liability or miscellaneous Errors & Omissions insurance?
What is the retroactive date?
Please select the coverage limit the applicant has in place for professional liability or miscellaneous E&O.
Please select the deductible the applicant has in place for the professional liability or miscellaneous E&O.
Please select the coverage type the applicant would like.
Does the applicant wish to purchase Prior Acts coverage?
How many years prior acts would the applicant like?
Does the applicant want Prior Acts coverage to end at the expiration of this policy?
Does the applicant wish to purchase Consent to Settle coverage?
Does the applicant currently purchase cyber or privacy liability insurance?
What is the retroactive date?
Does the applicant currently purchase media liability insurance?
What is the retroactive date?
Does the applicant currently purchase general liability insurance?
What is the name of the insurance company that provides the general liability coverage?
What is the effective date?
MM slash DD slash YYYY
Please enter the current coverage limit per occurrence.
Please enter the current aggregate coverage limit.
Please select the type of policy the applicant has.
Please list any notable exclusions.
Please upload loss runs (3-5) years.
Please upload copies of Professional Licenses if applicable.
Claims
In the past five years has the applicant, its directors, officers, employees or any other person or entity proposed for insurance, ever experienced disciplinary action as a result of professional activities? *
Please provide a description. *
Please provide the following additional details. *
In the past five years has the applicant, its directors, officers, employees or any other person or entity proposed for insurance, ever experienced claims made including any cyber privacy or network security incidents? *
Please provide a description. *
Please provide the following additional details. *
In the past five years has the applicant, its directors, officers, employees or any other person or entity proposed for insurance, ever sued a client to collect fees? *
Please provide a description. *
Please provide the following additional details. *
Is any person or entity proposed for insurance aware of any fact, circumstance or situation which he or she has reason to suppose might give rise to a claim that would fall within the scope of the proposed coverage? *
Please provide a description. *
Please provide the following additional details. *
Policy Limits
Please select the options you would like quoted for this Errors & Omissions policy. (Per Incident/Aggregate)
Please enter the Errors & Omissions liability limit(s) you would like quoted.
Please choose your desired deductible(s) for this proposal.
Please enter your desired deductible for this proposal.
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
Please share what you typed into Google.
Please share how you heard about us.
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.
Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes.
