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Business Insurance
Business Insurance Form
Proposed Effective Date :
Owners Name :
Name of Business :
Phone No :
Fax No :
Domain Name :
Email Address :
Address :
Business Description :
Additional Insured (relationship, name and mailing address) :
General Liability
Type of corporate entity :
Select
Individual/Sole Partnership
Joint Venture
Partnership
Corporation
Limited Liability Company
Date operation began under current ownership :
If Date operation less than 3 years, please give related experience and/or education:
Number of Applicant’s Principals :
Domestic Gross Revenues (Actual or estimated) :
Primary Liability Limits :
Select
$500,000 Occurrence / $1,000,000 Aggregate
$1,000,000 Occurrence / $2,000,000 Aggregate
$2,000,000 Occurrence / $4,000,000 Aggregate
Number of Applicant’s Technical Professional Staff (excluding Principals) :
Number of Applicant’s Clerical / Administrative Staff :
Foreign Gross Revenues (Actual or estimated) :
Are you designing software that involves any of the following:
Military/Nuclear Software?
Century Change Problems?
Robotics or heavy machinery controls?
Heat,temperature or fluid level monitoring?
Financial Institution Software?
Automated Quality Control?
Alarm, warning or remote sensing systems?
If yes, plase explain in detail:
Umbrella Liability
Number of autos legally titled in your Business name:
Umbrella Limits Requested :
$1,000,000 Each Occurrence / Aggregate
$2,000,000 Each Occurrence / Aggregate
$5,000,000 Each Occurrence / Aggregate
None of the above
Workers Compensation
Federal Employer ID :
Outside Salespeople (payroll) :
Clerical (payroll) :
Software Dev. (payroll) :
Employer’s Liability Limits :
$500,000 each accident; $500,000 disease Policy Limit $500,000 disease- each employee
$1,000,000 each accident; $1,000,000 disease Policy Limit $1,00,000 disease- each employee
Number of Employees :
Administrative (payroll) :
Maintenance (payroll) :
Other Payroll :
Loss Information (Last 5 years):
Are you engaged in any other type of business?
Yes
No
Are physicals required of new employees :
Yes
No
Any group transportation provided?
Yes
No
Any subcontractors used?
Yes
No
Any part-time, seasonal, volunteer or donated labor?
Yes
No
Any labor interchange with any other business?
Yes
No
Do you lease employees to/from other employers?
Yes
No
Any employee under 16 or over 60?
Yes
No
Own/operate or lease aircraft/watercraft?
If you answer “yes” to any of the above, please explain in detail:
Applicant’s current professional liability:
Insurer :
Retro Date :
Limit :
Premium :
Has any claim(s) been made against the applicant in the last five (5) years?
Is applicant aware of any potential claim or situation which may reasonably be expected to become a claim against your firm?
Please provide the following documentation:
Software License Agreement
Sales Agreement
Distribution Agreement with Software and/or Hardware Manufacturer
Consulting Agreement
This application does not bind the company or applicant, nor does it obligate the company to insure applicant services or issue a policy. If a policy is issued, the company may cancel such policy upon discovery of fraudulent statements, omission or concealment of the facts material to the acceptance by the company.
The applicant also warrants that such statements and responses are true, contain no misrepresentation and that if the information that is supplied on this application or attachments changes between the date of this application and the inception date of the policy, the applicant will immediately notify the company of such changes.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance concerning any material fact thereto, commits a fraudulent act, which is a crime. In New York, any person shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.
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