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Technology Professional Liability Renewal Questionnaire
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Applicant Information
Who is applying for this insurance? *
*
Who is applying for this insurance? *
What is the applicant’s address? *
*
What is the applicant’s address? *
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
What is the applicant’s website address? (Enter http:// or https:// first)
What is the applicant’s website address? (Enter http:// or https:// first)
What is the applicant’s email address? *
*
What is the applicant’s email address? *
Enter your technology professional liability policy number.
Enter your technology professional liability policy number.
Enter your technology professional liability policy's renewal effective date.
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 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 domestic revenue for the next 12 months.
Please provide your projected foreign 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)
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 select what has occurred the past 12 months or may occur in the next 12 months. (Select all that apply)
Merger
Acquisition
Newly Formed Owned Identity
Name Change (No Merger & Acquisition)
New Products or Services
None
Please describe the merger in detail.
Please describe the merger in detail.
Please describe the acquisition in detail.
Please describe the acquisition in detail.
Please describe the newly formed owned identity in detail.
Please describe the newly formed owned identity in detail.
Please describe the name change (No merger & acquisition) in detail.
Please describe the name change (No merger & acquisition) in detail.
Please describe the new products or services 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.)
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.)
Yes
No
Please provide a description of the new contract(s) that exceed 25% of your total revenue.
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 size of the contract? (Dollar amount)
What is the length of the contract? (Months)
What is the length of the contract? (Months)
What is the name of the client?
What is the name of the client?
Please describe the work being provided.
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?
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?
Yes
No
Please describe in detail.
Please describe in detail.
Have you sued a customer for failure to pay for products or services rendered in the past 12 months?
Have you sued a customer for failure to pay for products or services rendered in the past 12 months?
Yes
No
Please describe the reason for non-payment, if known.
Please describe the reason for non-payment, if known.
Please describe the outcome of the lawsuit.
Please describe the outcome of the lawsuit.
Please provide the date the lawsuit was resolved.
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.?)
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.?)
Yes
No
Please explain what happened.
Please explain what happened.
What was the impact of the security incident on your business?
What was the impact of the security incident on your business?
Explain any actions taken to prevent any future network security breach or attack.
Explain any actions taken to prevent any future network security breach or attack.
Insured Signature
Enter signer's full name. *
*
Enter signer's full name. *
Enter signer's title.
Enter signer's title.
Enter signer's signature.
Enter signer's signature.
Documents and Comments
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)
Please use this field to upload any relevant insurance documents. (ie. Current policy declarations pages, appraisals, etc...)
Drop files here or
Select files
Accepted file types: pdf, jpg, Max. file size: 128 MB, Max. files: 5.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
How did you hear about us?
How did you hear about us?
Referred by...
Google search
Agency's website
Email newsletter
Current customer
Facebook
Instagram
Twitter
Other
Please share who referred you to us.
Please share who referred you to us.
Please share what you typed into Google.
Please share what you typed into Google.
Please share how you heard about us.
Please share how you heard about us.
Consent
*
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. *
I agree *
Gates Skene
601-968-0256
https://www.rossandyerger.com/private-client-group
gskene@rossandyerger.com
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