Who is applying for this insurance? *
What is the applicant’s address? *
What is the applicant’s website address? (Enter http:// or https:// first)
What is the applicant’s email address? *
Enter your technology professional liability policy number.
Enter your technology professional liability policy's renewal effective date.
MM slash DD slash YYYY
Please enter the year(s) it will be during the next 12 months.
Please provide your projected domestic revenue for the next 12 months.
Please provide your projected foreign revenue for the next 12 months.
Total global revenue for the next 12 months. (Calculates automatically)
Please select what has occurred the past 12 months or may occur in the next 12 months. (Select all that apply)
Please describe the merger in detail.
Please describe the acquisition in detail.
Please describe the newly formed owned identity in detail.
Please describe the name change (No merger & acquisition) in detail.
Please describe the new products or services in detail.
Have you entered into any new contracts over the past 12 months that exceed 25% of your total revenue? (If Yes, additional underwriting information may be requested.)
Please provide a description of the new contract(s) that exceed 25% of your total revenue.
What is the size of the contract? (Dollar amount)
What is the length of the contract? (Months)
What is the name of the client?
Please describe the work being provided.
Are you aware of any actual or alleged facts or circumstances, or potential situations, which could reasonably be expected to give rise to a claim under this policy?
Please describe in detail.
Have you sued a customer for failure to pay for products or services rendered in the past 12 months?
Please describe the reason for non-payment, if known.
Please describe the outcome of the lawsuit.
Please provide the date the lawsuit was resolved.
MM slash DD slash YYYY
In the last 12 months, has your network, website, or mobile devices been subjected to any type of security incident or attack (e.g. viruses, malware, denial of service attacks, etc.?)
Please explain what happened.
What was the impact of the security incident on your business?
Explain any actions taken to prevent any future network security breach or attack.
Enter signer's full name. *
Enter signer's title.
Enter signer's signature.
Documents and Comments
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)
Accepted file types: pdf, jpg, Max. file size: 128 MB, Max. files: 5.
Drop files here or
Please enter any additional remarks in the space below.
How did you hear about us?
Please share who referred you to us.
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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. *