Technology - Hutch

Technology – Hutch

Business

Business name:

Legal entity:

Number of employees:

Contact name:

First Last

Phone:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other location(s):

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email:

Website / Social Media:

Annual sales:

Annual payroll:

Federal tax ID number:

Franchise:

Current carrier:

Years with current carrier:

Policy expiration date:

Number of claims:

Claim(s) details:

Underwriting

Has the Applicant ever been canceled (incl. nonpay) or refused insurance of any kind by ERIE or any other insurance carrier?

If yes, please explain:

Has the Applicant filed for bankruptcy in the past 5 years?

If yes, please explain:

Property

Blanket

Deductible amount:

Coinsurance amount:

Replacement cost value:

Actual cash value:

Building value:

BPP / Contents:

Additional Property (signs, lights, clocks, fences, playgrounds, etc.)

Physical address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

County:

Construction type:

Year built:

Year of roof:

Total square footage:

Your square footage:

List other tenants:

Sewer / Drain:

Money & Securities:

Tools off premises:

Include enhancement endorsement

General Liability Limit

Select one:

Umbrella?

Rating basis:

Sales / Receipts:

Payroll:

Data Breach liability:

Employee benefit liability:

Employment practices liability:

Deductible:

Number of Employees (full-time):

Number of Employees (part-time):

Third-party coverage?

Technology E&O Exposures

Do you currently have E&O coverage?

Have you ever been declined for E&O coverage or had coverage canceled or nonrenewed?

Have you had any E&O claims in the past three years?

Are you aware of any circumstances that could reasonable be expected to give rise to an E&O claim?

Have you sued a customer for failure to pay for products or services rendered in the past three years?

Have you had to recall any of your products or services in the past three years?

Do you have contracts exceeding $1,000,000?

Are written contracts required with all customers?

Which of the following are included in your contracts with customers?

Hold harmless / Indemnification

Remedies for contract disputes or breaches

Warranty disclaimers

Guarantees

(Check all that apply)

Do you incorporate any of the following Risk Management measures in your operation?

Hold harmless / Indemnification

Remedies for contract disputes or breaches

Warranty disclaimers

Guarantees

(Check all that apply)

Do you currently have guidelines in place to safeguard against infringing the copyrights / trademarks of others?

Have you hired an employee from a competitor with access to trade secrets in the past 12 months?

Do you collect specific information?

(ex: from site visitors)

Do you share, sell, or give this information to outside parties?

If yes, is user permission obtained?

Do you have a privacy disclosure statement on your website?

Does your content or software include any electronic information gathering?

(spyware / adware)

Are you doing any programming or software design?

If yes, please describe:

Do you perform security audits?

How often are computer systems and data backed up?

Is this stored off sight?

Are all contracts reviewed by your legal counsel?

Do you use subcontractors?

Do you require that your subcontractors via a signed legal binding contract include you as an additional insured?

Do you require that your Subcontractors carry a minimum of $1M of E&O?

Do you require that their policy be made primary and non-contributory?

Do you collect certificates of insurance from your Subcontractors?

Do you provide services for any of the following industries?

(Check all that apply)

Workers’ Compensation

Expert modification factor:

Expert modification date:

Sole proprietor / Partners coverage?

Corporate officer coverage?

List

Class code #:

Payroll =

Average length of employment:

Safety:

(check all that apply)

Eye washing stations?

Autos

Auto used in business?

Autos titled to?

Hired / Non-owned?

Do your corporate officers maintain a personal auto policy?

If no, consider adding the corporate officers named coverage endorsement.

Included at direct primary

Limit is actual loss

Liability

Med Pay

Um / Uim

Comp

Coll

List

Year

Make

Model

VIN

Documents

Check box when complete:

Loss runs