Get A Quote (Tech)

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Fields

General Information

Name*

Phone*

Email*

Name Of Company:*

Address*

Website*

Year Established*

Gross Annual Revenue*

Percentage Of Sales From Website/Online*

Please Describe Your Business' Operations And Allocate Revenue As A Percentage For Each Product Or Service Provided*

Effective Date Of Coverage

1-7 Days 7-30 Days 1-2 Months

Have There Been Any Claims Or Losses In Prior 3 Years (Loss Runs Ordered At Binding)*

Goals For Re-Marketing

Improved Broker Relationship Or Expterise Improved Coverage or Coverage Assessment Seeking Reduction In Premium

Please List Carriers From Which Quotes Have Already Been Obtained

Product

CommercialLiabilityProperty TechnologyProfessionalLiabilityEO EmployersLiabilityWorkersCompensation DirectorsOfficersincludingEPLI CyberLiability CrimeFidelityincluding3rdParty

Industry

E-Commerce Companies Fintech Online Media, Marketing & Entertainment Software Development & Consulting Cloud Services & Platforms IT Staffing

Technology Professional Liability (E&O)

Current E&O Premium With Any Excess / Umbrella

Limit Being Requested*

Average Contract Length*

1-3 Months 3-6 Months 6-12 Months 1-2 Years Not Applicable

Please Indicate Largest Contract Size And Average Contract Size Dollar Ammount*

Do You Provide Any Hosting, Consulting, Storage Of Data Or Additional Services. If So Please Describe*

Please Describe Any Fees Associated With The Design, Implementation, Consulting Or Installation Of Products Or Services

Do Standardized Contracts Contain The Following*

We Do Not Use Standardized Contracts Description Of Services And Payment Terms Hold Harmless Agreements In Your Favor Hold Harmless Agreements In Your Clients Favor Guarantees Or Warranties

Do You Perform Any Of The Following*

Reviews To Ensure Work Is Within Scope of Capabilities Intellectual Property Checks To Prevent Breaching IP Of Others Security Testing Of Website & Software None Of The Above

Within Past 5 Years Have You Acquired Or Merged With Another Entity*

Yes No

Do You Utilize Sub-Contractors*

Yes No

Please Indicate The Retroactive Date Of Your Current Policy If Known

Please Describe Any Parent Companies Or Subsidiaries

Attach Copy Of Policy

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Cyber Liability

Address Of Website*

Limit Being Requested*

Current Carrier & Premium

Retroactive Date Of Current Policy (If Known)

Doe You Collect, Store Or Transmit The Following*

Credit Card Or Bank Data Personal Information (DOB's, Social Security Info) Personal Health Or Medical Information Employee & HR Information Intellectual Property Of Others None Of The Above

Approximate Number Of Individual Records Stored On Network*

1 - 10,000 10,000 - 100,000 100,000 - 500,000 500,000 - 1 Million 1 Million - 5 Million

Do You Provide Any Hosting Or Data Storage For Clients Or Others*

Yes No

Is Data Encrypted*

Yes No

Please Describe Existing Firewall, Security Measures, Testing & Backup Procedures*

Attach Copy Of Policy

No File Chosen

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