TECH InNAVation(sm)
PROFESSIONAL LIABILITY INSURANCE

 NAVIGATORS INSURANCE COMPANY 

THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY
APPLICANT’S INSTRUCTIONS

A.	ALL QUESTIONS MUST BE ANSWERED COMPLETELY.  PLEASE TYPE OR PRINT CLEARLY.  IF ANY QUESTIONS ARE CONSIDERED “NOT APPLICABLE”, PLEASE EXPLAIN WHY.
B.	PLEASE USE THE COMMENTS LINE(S) FOR ADDITIONAL INFORMATION OR CONTINUE ON A SEPARATE ADDENDUM INDICATING THE QUESTION NUMBER/SUPPLEMENT.
C.	PLEASE COMPLETE THE APPLICATION FORM AND SUPPLEMENT WHERE REQUIRED.
D.	THIS APPLICATION AND ALL SUPPLEMENTS MUST BE SIGNED AND DATED BY A PRINCIPAL OF THE FIRM.
E.	THE TERM “LAWYER” IN THIS APPLICATION SHALL MEAN ANY PARTNER, EMPLOYED LAWYER, “OF COUNSEL” OR CONTRACT LAWYER.
F.	THIS APPLICATION MAY ASK FOR DETAILS ON ACTIVITIES FOR WHICH NO COVERAGE IS PROVIDED UNDER THE INSURANCE BEING REQUESTED.  PLEASE CONSULT WITH YOUR BROKER OR INSURANCE AGENT FOR DETAILS OF YOUR PROPOSED COVERAGE.

	1. Applicant’s contact information:
Full name (company name as it is to appear on the policy, if issued): _____________________________________________________________________
Street Address ________________________________________________________
	City_____________________________________	County ___________________
	 State______  Zip_________	

Phone # _______________________  Fax# ________________________________

Email Address _______________________

Domain Address, if any _______________________

	2.    a. Is the Applicant a: ______ Corporation_____ Partnership _____ Individual ______L.L.C.
______ Other (please describe) __________________________
	                   b. Date operations began under current ownership _____________(month/day/year):	/_~.

3.	Describe in detail Applicant’s services including any areas of specialization;
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4.	Contracts and Agreements:
a.  Have you use a standard contract or engagement letter?            ____ Yes  ____ No
b.  Do you require 100% of clients to sign this contract?	      	____Yes   ____ No 
	lf no,” what percent? ________ %
c.  Do you ever sign contracts provided by your client?		____ Yes  ____No 
	If yes, what percentage of the time do you sign your client’s contract? 
d.  Does your standard contract contain Hold-harmless or indemnity agreements? ____ Yes  ____No
e.   Does your standard contract contain specific description of professional services?   
      	____ Yes  ____ No
f.  Does your standard contract contain Limitation of Liability wording? ____ Yes  ____No	                                             

5. Do you have General Liability insurance currently in-force?	     	____Yes   ____ No

6. Number of Applicant’s Principals:
Number of Applicant’s Technical / Professional Staff (excluding Principals):________________
Number of Applicant’s Clerical / Administrative Staff:__________
# Total Employees:_____________________

7. Applicant’s gross revenues (domestic only)
Future 12 months (projected) $___________
Previous 12 months                $___________
The year before last	 $ ___________

Applicant’s foreign revenue if any
Future 12 months (projected)          $ ___________
	Previous 12 months		   $ ___________
	The year before last	   $ _______________________

8.	Are any revenues contingent upon a guarantee of customer savings resulting from the use of your services
	 _______Yes        ______ No
	Are the costs of your services ever reduced if deadlines are missed? 
	_____ Yes _____ No 
If yes, please explain______________________________________________________________

Please indicate the percentage of your annual revenue from end clients in the industries below:
_______% Manufacturing		_______% Aerospace		_______%Banking/Investment

_______% Insurance		_______  % Telecommunications	_______% Software Development

________ % Transportation	_______ % Education 		_______ % Retail
		
_______ % Government		_______% Utilities		_______% Internet

_______% Medical & Pharmaceutical	_______% Medical: Life Support	_______% Entertainment	

_______% Construction		_______% Advertising		_______% Other

9.	Please indicate the percentages of your annual revenue involving the following services:
______Staffing					______Database Design/Management
______System Design/Administration/Engineering	______Financial Transaction Software
_____ Network Design & Administration		_____ Hardware Only Installation & Maintenance
_____ Hardware Sales				_____ Application Service Provider*
_____ Computer Security*				_____ Content/FTP/ Search Services
_____ Technical Writing				____ Manufacturing Software (Robotics, PLC, CAM)
_____ Medical Management			_____  Disaster Recovery Planning/Backup Services
_____ Business Application Software Development	_____ Office Automation
_____ Accounting/Financial/Payroll (no finds transfer)	_____ ERP Implementation/Maintenance
_____ Software/Hardware Installation & Maintenance	_____ Software Sales
_____ Web Hosting				_____ Web Design, Development/Graphic Design
_____ E-Commerce				_____ Training & Education
_____ Telecommunication Consulting		_____ CAD (Non-structural)
_____ Medical Diagnostic Software/Hardware		_____ Other 

10.	If you provide network or Internet security services, please answer the questions below:
a)	Do you implement back-up procedures for client?	_____ Yes _____ No
b)	Do you obtain a signed contract for all projects?	_____ Yes _____ No
c)	Is security specifically addressed in the contract?	_____ Yes _____ No
d)	Does the contract specifically stipulate that such work is not guaranteed to prevent intrusions?	_____ Yes _____ No
e)	‘When you use licensed security software, do you require that the client accept in writing the terms, conditions, and limitation of the software’s license agreement?			_____ Yes _____ No

f)	What percentage of you security work is based on original code or custom applications?         _________%
g)	What percentage of your security work incorporates security software licensed from vendors?_________%
What is a typical security project description? (Please describe, use attachment if necessary)
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

11. 	If you are an Application Services Provider, please answer the questions below:
a.	Are off-site backups of web sites and associated programs done daily?	_____ Yes _____ No
b.	Please describe the system security measures you are currently using;
 ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
c.	Explain contingency plan to restore service to customers in the event of an outage:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

12.	Project Management: If you develop software or manage projects, please answer the questions below:
If any of the above questions were marked Not Applicable (NA), please explain why.	_____ Yes _____ No
	a)	Is system design work documented and tested?				_____ Yes _____ No
	b)	Is documentation retained for the life of the system?				_____ Yes _____ No
	c)	Are test plans followed for all software/program modifications?			_____ Yes _____ No
	d)	Do clients have responsibility for confirming accuracy of system?		_____ Yes _____ No
	e)	Has the applicant implemented a written contingency plan?			_____ Yes _____ No
	f)	Do you require a written client sign-off on completion of the assignment?	_____ Yes _____ No
	g)	Do you implement back-up procedures for client?				_____ Yes _____ No

If you have answered “No” to any of the above questions(15a-g) please explain, use attachments if necessary;
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. What percentage of work is sub-contracted?		_________%
	Do you use standard contract with sub-contractors?  	_____ Yes _____ No
	Do you require them to carry E&O insurance?	_____ Yes _____ No

14.	Project Administration - Does Applicant:			
	  a) Provide client with a written definition of the job?             _____ Yes _____ No	
	  b) Written estimate of time and cost?	                _____ Yes _____ No
	  c) Develop weekly status reports?                                          _____ Yes _____ No	
	  d) Confirm in writing, client requested changes?                   _____ Yes _____ No	
	  e) Confirm acceptance criteria on client requested changes? _____ Yes _____ No	

15.  For Internet/On-Line Service Providers only. Other applicants please skip to question 19:
a.	Please check the appropriate services and indicate percentage of revenue from each service:

_____ Web Hosting			_____%
____ Web Page Designer		_____%
_____ Electronic Bulletin Board		_____%
	_____  FTP Site                                        _____%
	_____ Intemet Access Provider                _____ %	
	_____  Search Engine                             ______%	
	_____ Content Provider                          ______%
	_____ Other                                             ______%

Total number of subscribers (if applicable)
Internet address: ______________________________

b.	If you are providing web design services, please provide the UIRLs of 3 sites you have designed:
1.
2.
3.

c. Do you have any adult only web site clients? 	_____ Yes _____ No
d. If you provide Internet Access or FTP services, please provide the total number of subscribers: __________
e. If you provide search services, please provide the number of unique sessions per month. ____________
   f.	Do you maintain any editorial control over content? _____ Yes _____ No	
If you are a content provider, or maintain editorial control of Internet content check those applicable and provide details:
	___Adult Only	___Music ___Financial Information ___Advertising ___News  ___Health
	___Children	___Religious
Please provide details and include any other content provided;
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
g.	Do you sell any products or services (other than on-line products as described above) via the 
         internet?_____ Yes _____ No
If “Yes” please describe:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
h.	Do you offer Chat or bulletin board features? _____ Yes _____ No
If “Yes” please describe:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________	

16. a. Applicant’s current Professional Liability insurance:

	Name of Carrier: ______________________________ Retroactive Date: _____
Limits:	____________________________                                      SIR__________________
Annual Premium: ________________

b.	Has any application for similar insurance on behalf of the applicant or any of its partners, executive officers, directors, or to the knowledge of the applicant, on behalf of its predecessors in business ever been declined, cancelled or renewal refused?	_____ Yes _____ No
	If Yes, explain on separate paper

17. Claim History
a.	After inquiry, does the applicant, any director, officer, employee or partner of the applicant have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim? _____ Yes _____ No 
	If yes, explain on separate paper.

b.	Have any claims been made during the past five years against the applicant, their predecessors in business or any of the present or past partners? 	_____ Yes _____ No
If yes, provide details on a separate paper. Include the date of the event, the date reported to your insurer if applicable, amount incurred in legal defense and any other payments made by you or on your behalf.	_____ Yes _____ No

21. Please provide the following documentation, if applicable:
•	Consulting Agreement (your standard contract)
•	Software License Agreement
•	Distribution Agreement with Software and/or Hardware Manufacturer
•	Sales Agreement

Please mark the services you provide below.

_______Research and Development Services as described below:

•	Technology research and development.
•	Development, dissemination and publishing of research data.

_______Disaster Recovery Planning and Consulting as described below:

•	Off-site media storage facilities to protect against data loss resulting from disasters such as fires, floods, brownouts, computer failure, employee errors, employee sabotage, pickup and delivery of media.
•	Back-up computer hardware and software facilities, hot and cold sites, relocation services, handling of all electrical power, phone cable, mail, telephone, human resources support during a disaster, and security services to protect property from theft, damage, destruction or sabotagc while off site.
•	Auxiliary services such as cleaning, testing and evaluation of tape and disc media, restoration of damaged tapes, updating of media and purging of files.

_______Electronic Data Processing and Electronic Data Processing Consulting as described below:

•	Conversion of data from source material into a form of media for processing on electronic data processing machines and the subsequent processing of such data.
•	Performance of feasibility studies, giving opinions or recommendations regarding electronic data processing objectives and needs.

______Software Programming (includes maintenance) as described below:

•	Writing, testing and installation of computer programs. Writing of program documentation and the performance of maintenance on established programs.

Database Management and Consulting including design, development and maintenance.

_______Systems Analysis/Software Design as described below:

•	Analysis of information needs including the recommending, planning and designing of electronic data processing systems and procedures.

______ System Integration including consulting, and on-site installation of hardware andlor packaged software.

_____Multimedia and Interactive Software Development and Consulting as described below:

•	Combining text, video, voice, computer, and telephone technologies into a multimedia network.
•	Consulting on conversion of existing technology into digital form.
•	Providing switching technology and consulting to connect different networks.

______Image Processing Systems including management, consulting and/or maintenance services.

_______ On-Line Publishing and Consulting Services including Home Page design and consulting.

______Internet Service Provider including access and web hosting.

______Reselling Hardware, software and systems

______Training and Education

______ Information Technology Staffing and Placement services including short and long term.

______ Other as described below (please use attachment)

The Applicant declares and warrants that, after enquiry, to the best knowledge of all persons to be insured the statements set forth herein and in any attachments made hereto are true and no material facts have been surpressed omitted or misstated.  The Company reserves the right to deny or rescind coverage on any Policy that is issued as a result of this Application if, in the statements set forth herein and in any attachments made hereto it is found that material information has been omitted, surpressed or misstated.

The Company also reserves the right to amend the terms, conditions and limitations, coverage of any Policy that is issued as a result of this Application, if subsequent to the date of this Application, but prior to the inception date of such policy, there are any material alterations to the information contained herein.  In the event of such material alteration, as aforesaid, the Applicant agrees to give immediate written notice to the Company and such notice shall attach to and form part of this application.

Signing this Application does not bind the Applicant or the Company to complete the Insurance, but it is agreed that the statements and particulars contained herein will be relied upon by the Company should a Policy be issued.

This application is signed on behalf of all Owners, Partners, Shareholders, Corporate Officers and Employees.

Fraud Warning:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.  Arkansas and Louisiana Fraud Warning:  Any person who knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.  Colorado and Virginia Fraud Warning:  It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company.  Penalties may include imprisonment, fines, denial of insurance benefits, and/or civil damages.  In Colorado, any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department or regulatory agencies.  Florida Fraud Warning:  Any person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony of the third degree.  Kentucky Fraud Warning:  Any person who knowingly and with intent to defraud any insurance company or another person, files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties. Minnesota Fraud Warning:  A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.  New York Fraud Warning:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.  Oklahoma Fraud Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Ohio Fraud Warning:  Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oregon Fraud Warning:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which may be a crime. Tennessee Fraud Warning:  It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company.  Penalties include imprisonment, fines and denial of insurance benefits.	
	
AUTHORISED SIGNATURE OF APPLICANT		TITLE	
Must be a principal of the Applicant and a person at risk			

			
			
Date		Effective Date Requested for this Insurance	

PLEASE MAKE CERTAIN ALL QUESTIONS ARE ANSWERED AND THAT ALL APPLICABLE SUPPLEMENTS ARE COMPLETED.THIS APPLICATION WILL NOT BE PROCESSED UNLESS ALL QUESTIONS ON THIS APPLICATION AND APPLICABLE SUPPLEMENTS ARE ANSWERED.