Professional Liability Interactive Information &
Communication Technology Insurance Application

Professional Liability
Interactive Information & Communication Technology
Insurance Application

IMPORTANT: Please answer ALL questions fully. If there is insufficient space please provide details on your letterhead.
Where provided tick (?) appropriate box to indicate answer. The Applicant will be referred to in this Application as “You” or “Your”.

The Applicant/s
Name(s) in full of all entities to be insured:		ABN:
Input Tax Credit:		Telephone No.
Web Address		Fax
Address of head/principal office		State
When was the business established?		Post Code
Current Insurance Expiry Date?		Period of insurance From
To 4pm on

Details of Business
1. Please provide details:
(a) The precise nature of the activities of the business, including primary purpose of software/systems provided, sold or licensed including details of any advice provided.
Please provide the amount for the following:				Australia			Overseas
(b) Number of Employees
(c) Annual gross turnover current financial year
(d) Annual gross turnover estimated next financial year (12 months)
(e) Please provide the approximate percentage of your activities (based on turnover) applicable to each State, Territory and Overseas
NSW	VIC	QLD	SA	WA	TAS	NT	ACT	O/S

(f) The approximate percentage of your gross turnover derived from the following business activities.
Hardware sales (Reseller)
Hardware sales (Own developed or exclusive importer)
Pre-packaged Third Party software sales (Reseller)
Pre-packaged software sales (Own developed or exclusive importer)
Application software development/contract programming
Data communication services (ISP)
Telecommunication services.
Network services.
Help Desk services.
Maintenance services.
Data processing/warehousing services.
Bureau services.
ICT Project Management General consultancy.
Integration services.
Billing Services.
Education and Training? Yes No If “Yes”, please complete Questions 20 and 21
Other (Please describe).
Total

Cover Required
Name(s) in full of all entities to be insured:	Limit of Indemnity	Deductible
Section A – Errors or Omission
Section B – Bodily Injury/Property Damage

Optional Extensions
Increased Aggregate Liability (Reinstatement)	yes no
Third Party Intellectual Property Coverage	yes no
USA and Canada Coverage	yes no
Covered Contractors	yes no

Claim Details
2. (a) After enquiry have any claims for negligence or breach of professional duty, personal injury or property damage been made in the last ten (10) years against the Business or any of its predecessors in business or any prior business of any of its former Partners, Principals or Directors, or have circumstances been notified to insurers that might give rise to a claim? If “Yes”, please provide the following details in respect to each matter.					yes no
Name of Insurer (if any)	Date of Matter MM/YYYY	Name of Claimant or Potential Claimant	Brief Description of Matter	Amount Paid or Estimate of Potential Liability	Is Matter Finalised or Outstanding?




(b) After enquiry, is any applicant aware of any claim or circumstances that might give rise to a claim against the Business or any prior business of any of their present or former Partners, Principals or Directors, which matter is not referred to above? If “Yes”, please provide the following details in respect to each matter.					yes no
Name of Insurer (if any)	Date of Matter MM/YYYY	Name of Claimant or Potential Claimant	Brief Description of Matter	Amount Paid or Estimate of Potential Liability	Is Matter Finalised or Outstanding?




(c) After enquiry has any applicant ever been subject to disciplinary proceedings for professional misconduct? If “Yes”, please supply details.					yes no

(d) Has any applicant ever had a Professional Liability Insurer decline to continue the applicant’s insurance or cancel their insurance? If “Yes”, please supply details.					yes no

Risk Details
3. In the last 5 years, has any applicant been declared bankrupt? If “Yes”, please supply full details.		yes no

4. In the last 5 years, has any applicant been the subject of administration proceedings? If “Yes”, please supply full details.		yes no

5. In the last 5 years, has any applicant been convicted of any criminal offence (other than minor traffic convictions)? If “Yes”, please supply full details.		yes no

6. Other than New Zealand, does the applicant conduct business in any overseas Country? If “Yes”, please provide an approximate percentage breakdown by Country or client.		yes no

7. Does the applicant provide any services with respect to any stock exchange, broking or clearing house systems? If “Yes”, please supply full details.		yes no

8. Is the applicant undertaking any custom project or program within excess of 20% new code? If “Yes”, please supply full details.		yes no

9. Does the applicant provide any services with regard to projection planning or financial analysis? If “Yes”, please supply full details.		yes no

10. Does the applicant have any software or program within any stage of beta testing? If “Yes”, please supply full details.		yes no

11. Does the applicant provide any services with respect to any security systems? If “Yes”, please supply full details.		yes no

12. Has the applicant provided services to integration projects with more than 75 users and multi-users locations? If “Yes”, please supply full details.		yes no

13. Does the applicant provide any services with respect to the manufacture, or supply of switching components, including but not limited to routers? If “Yes”, please supply full details.		yes no

14. Does the applicant provide any services with respect to any components that are integrated into equipment in the following industries? Manufacturing Medical Mining Transport Military Gaming. If Yes please supply full details.		yes no

15. Does the applicant provide any services with respect to the manufacture of semi-conductors? If “Yes”, please supply full details.		yes no

16. Does the applicant provide any services with respect to help desks only?		yes no

17. Does the applicant provide maintenance services only?		yes no

18. Does the applicant provide back up and remote storage facilities? If “Yes”, please supply full details.		yes no

19. Has the applicant discontinued developing, manufacturing or producing any hardware products? If “Yes”, please supply full details.		yes no

20. Is the applicant a registered training provider? If “Yes”, please supply full details.		yes no

21. Does the applicant provide formal qualifications? If “Yes”, please supply full details.		yes no

22. Has any contract or project experienced cost overruns, delays in implementation, failure or system(s) or product(s) to meet full functionality? If “Yes”, please provide details		yes no
Client/Contract Name	Brief Description or Problem





23. Are any of the applicant’s products or services intended for use in industrial control systems/SCADA/robotics, aviation, radar, aircraft, watercraft, military installations or warfare equipment, any surgical or medical applications or equipment or any pollution control systems or any artificial intelligence application or system? If “Yes”, please supply full details.		yes no

24. Are any of the applicant’s products or services intended for use in any gambling or wagering system or the provision of any adult content or pornographic materials? If “Yes”, please supply full details.		yes no

25. Are the applicant’s exclusive importers and/or distributors of computer software, computer systems or hardware? If “Yes”, please supply full details.		yes no

26. Does the applicant enter into any hold-harmless agreements or otherwise waive any legal rights or entitlements which they may have against such consultants, sub-contractors or agents? If “Yes”, please supply full details.		yes no

27. Is more than 25% of the applicant’s total fees/income derived from the Finance and Banking sector? If “Yes”, please supply full details		yes no

28. Have any of your clients refused payment or requested a refund of monies paid? If “Yes”, please provide full details.		yes no
Client	Amount of Refund or Non Payment





29. Have any of your clients refused payment or requested a refund of monies paid? If “Yes”, please supply full details.		yes no

30. Are consultants, sub-contractors or agents engaged by the applicant required to carry their own professional Indemnity Insurance? If “No”, please supply full details.		yes no

31. Prior to providing any contractual indemnity to anyone in respect of intellectual property licensed sold or shared, does the applicant retain the sole legal rights to such intellectual property licensed/sold/shared? If “No”, please supply full details.		yes no

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Professional Liability Interactive Information & Communication Technology Insurance Application

Professional Liability Interactive Information &
Communication Technology Insurance Application