Combined Liability Insurance. Information and Communication Technology Proposal form

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1 Comined Liility Insurnce Informtion nd Communiction Technology Proposl form

2 Comined Liility Insurnce Informtion nd Communiction Technology - Proposl form This proposl form must e completed nd signed y principl, director or prtner of the proposed insured. Cover nd quottion requirements Required limit Required excess Professionl Indemnity Commercil Liility Pulic liility, including Products nd pollution Employers liilty Previous cover Hve you previously een insured in respect of Professionl Indemnity, Pulic Liility or Employers Liility? If Yes plese provide detils (UNLESS YOU ARE INSURED WITH QBE) Professionl Indemnity Pulic Liility Employers Liility Insurer Limit of indemnity Excess (ech & every clim) Premium Expiry dte 3398/COMBINEDLIABILITY/ICTPROP/APR2014 P2 / 9

3 1 Compny informtion Compny nme Wesite ddress Postl ddress Postcode Emil ddress Other trding ddresses Postcode Postcode 2 If you require cover for ny ssocited or susidiry compny plese provide compny nmes, including, if pproprite, detils of ny joint venture prtner: All informtion given in the proposl form must relte to ll compnies to e covered y the insurnce. 3 Are you represented in ny overses loctions? If Yes plese provide detils: 4 Do the prtners or directors of the firm hve t lest 3 yers experience in the IT industry? If No plese provide rief CV of the prtners or directors 5 Plese provide totl numers of employees: 6 Plese provide detils of ny industry or professionl orgnistion of which you re memer: 7 Do you utilise the services of su-contrctors? If Yes wht percentge of work is generted using sucontrctors? c If Yes to (), do you ensure they hve their own PI insurnce? If No, plese provide detils: 3398/COMBINEDLIABILITY/ICTPROP/APR2014 P3 / 9

4 8 Plese provide full description of your usiness: (including min res of expertise nd the essentil purpose of proprietry softwre licensed or supplied): Plese provide copy of your usiness rochure or corporte profile. 9 Plese give rekdown of your turnover, including fee income, for the pst nd current finncil yers, nd estimte for the next yer: Finncil yer end (dte) Totl turnover including fee income: Pst yer (ctul) Current Yer (estimte) Next yer (estimte) Plese provide n estimted percentge split of turnover including fee income y geogrphicl territory: Pst yer (ctul) Current yer (estimte) Next yer (estimte) United Kingdom clients Europen clients USA nd Cndin clients NOT suject to USA/Cnd lw USA nd Cndin clients suject to USA/Cnd lw Rest of world clients Totl Wht is the wge roll of the compny (If Employers Liility not required do not complete)? Clericl/Administrtive Consulting Assemly/Networking Other (Plese provide detils elow) Plese provide detils of ny work conducted over 5 metres or offshore Plese provide detils of ny work involving the hndling of rdioctive mterils, sestos, silic, or ny dngerous gses or sustnces 3398/COMBINEDLIABILITY/ICTPROP/APR2014 P4 / 9

5 11 Plese provide n pproximte rekdown of your turnover including fee income, into the following ctivities: IT consultncy IT security consultncy IT trining Project mngement Bespoke softwre development Own shrink wrp softwre (sle) Own customisle softwre (sle) Third prty shrink wrp softwre (sle) Third prty customisle softwre (sle) Softwre mintennce own Softwre mintennce third prty Softwre instlltion Dt processing Wesite design Fcilities mngement We hosting Appliction hosting (including SS Softwre-s--Service) Online dt storge (including within cloud environment) Internet service provision Sle/supply of hrdwre Hrdwre mintennce Hrdwre instlltion Telecommuniction/networks Cling Other (plese descrie) Totl Pst finncil yer (ctul) 100 Current yer (estimte) 100 If the ove does not ccurtely reflect your estimted usiness ctivities moving forwrd, plese provide detils: 3398/COMBINEDLIABILITY/ICTPROP/APR2014 P5 / 9

6 12 Outsourcing services (ppliction hosting, softwre-s--service, online dt storge, fcilities mngement nd we hosting). If you crry out outsourcing services: c Where you re responsile for hosting nd storing third prty dt, do you comply with the 1998 Dt Protection Act? Do you hve usiness continuity pln to eliminte single point of filure for outsourcing services? Do you hve disster recovery pln? If No to ny of the ove, plese provide detils: 13 Are ny of your products/services: c d e Intended for use in ircrft, wtercrft, rilwy, militry hrdwre or process control equipment? Intended for use in nucler, chemicl, oil/gs/petrochemicl instlltion? Prototypes, experimentl or single product items? Intended for use in surgicl/medicl pplictions? Trding systems used in the finncil mrkets? If Yes to ny of the ove, plese provide detils: 14 Is the filure of ny of your products or services lile to result in ny of the following outcomes: c d e Loss of life or injury to person? Destruction or dmge to physicl property? Immedite nd lrge finncil loss? Significnt cumultive finncil loss? Insignificnt finncil loss (more of nuisnce)? If Yes to ny of the ove, plese provide detils: N/A 3398/COMBINEDLIABILITY/ICTPROP/APR2014 P6 / 9

7 15 Plese provide detils of the three lrgest projects commenced over the lst three yers: Completion Nture of project (including essentil Contrct Your totl fee Strt dte dte Client nd usiness purpose of product or service) vlue income 16 Plese estimte the vlue of the lrgest project you re likely to undertke in the next finncil yer: 17 How mny current customers do you hve? 18 Wht is the vlue of your verge contrct? 19 Wht is the durtion of your verge contrct? 20 Are ll contrcts suject to your stndrd terms nd conditions? If No, re ll contrcts vetted y leglly qulified person efore eing greed? If No, plese provide detils: (Plese provide copy of your stndrd contrct terms). 3398/COMBINEDLIABILITY/ICTPROP/APR2014 P7 / 9

8 21 When contrcting do you lwys: i exclude liility for consequentil, specil or indirect dmges, loss of profits nd liquidted dmges? ii cp your overll liility t resonle level? iii wrrnt performnce stndrd no greter thn resonle cre nd skill? iv ensure tht chnges to the scope of work re reflected in written vrition of the contrct? v only provide indemnities in respect of IPR, deth, odily injury or property dmge? vi ensure your contrcts stipulte dispute resolution procedure? If No to ny of the ove, plese provide detils: When tendering for usiness or entering into contrcts do you hve documented process in plce to ensure you cn deliver wht is expected of you? If No, plese provide detils: 22 Plese provide detils of ny mtter which my e relevnt to Underwriters considertion of your proposl nd which hs not een disclosed elsewhere in this proposl: 23 In respect of ny insurnce, hs ny Insurer ever declined proposl or renewl, imposed specil terms or cncelled or voided n insurnce policy? If Yes plese provide full detils: 3398/COMBINEDLIABILITY/ICTPROP/APR2014 P8 / 9

9 24 c d Hs ny clim of professionl indemnity, pulic liility or employers liility nture ever een mde ginst you or ny prtners, principls or directors? Hve you een involved in ny dispute or ritrtion concerning fees, products, services or intellectul property rights? Hve you sustined ny loss from the suspected dishonesty or mlice of ny employee? Are ny of your prtners, principls, directors or employees, AFTER ENQUIRY wre of or hve ny grounds for suspecting ny mtter which my give rise to clim ginst you or ny of your present or former prtners, principls, directors or employees? This includes: i shortcoming or prolem in your work known to you which you cnnot resonly put right: ii complint out your work or nything you hve supplied which cnnot e immeditely put right: iii n esclting level of complint on prticulr project: iv client withholding pyment due to you fter ny complint: If Yes to ny of the ove, plese provide full detils elow or on seprte sheet of pper: Declrtion I/We declre tht this proposl hs een completed fter pproprite enquiry nd tht the sttements nd prticulrs in this proposl (including ll ttchments, if pplicle) re true nd tht I/We hve neither misrepresented or suppressed ny mteril fcts. I/We undertke to inform Underwriters of ny mteril ltertion to these fcts whether occurring efore or fter the completion of the contrct of insurnce. Signture of Principl/Prtner/Director Dte 3398/COMBINEDLIABILITY/ICTPROP/APR2014 P9 / 9 QBE Europen Opertions is trding nme of QBE Insurnce (Europe) Limited, no ( QIEL ), QBE Underwriting Limited, no ( QUL ), QBE Mngement Services (UK) Limited, no ( QMSUK ) nd QBE Underwriting Services (UK) Limited, no ( QSUK ), whose registered offices re t Plnttion Plce, 30 Fenchurch Street, London, EC3M 3BD. All four compnies re incorported in Englnd nd Wles. QIEL nd QUL re uthorised y the Prudentil Regultion Authority nd regulted y the Finncil Conduct Authority nd the Prudentil Regultion Authority. QUL is Lloyd s mnging gent. QMSUK nd QSUK re oth Appointed Representtives of QIEL nd QUL.

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