Professional Liability

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Miscellaneous Professional Liability Questionnaire

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Section 1: General Information

(Note: If any affiliated entities or subsidiaries are to be included, please attach an organizational chart, and complete all questions in this application with respect to all entities to be covered)

Applicant:

Physical Address:

City, State, ZIP:

Mailing Address:

City, State, ZIP:

Website:

Contact Name:

Contact Phone:

Contact E-mail:

Year Established:

Nature of Operations:

Referred By

Additional documentation requested:

Résumés of principals, partners and key employees
Sample client contract
Sample sub-contractor contract, if applicable
Marketing materials

Section 2: Operations

1) Please provide annual revenues for:

Domestic:

Foreign:

Total:

Latest fiscal year end

Total number of employees-US

Total number of employees-OTHER

Total number of employees-TOTAL

Current fiscal year (projected)

Annual sales or revenue-US

Annual sales or revenue-OTHER

Annual sales or revenue-TOTAL

Next year (projected)

Estimated total number of records-US

Estimated total number of records-OTHER

Estimated total number of records-TOTAL

SECTION II – CURRENT COVERAGE

CURRENT CARRIER

EXPIRATION DATE

ANNUAL PREMIUM

LIMITS

RETENTION / DEDUCTIBLE

RETROACTIVE DATE

CURRENT CARRIER-1

EXPIRATION DATE-1

ANNUAL PREMIUM-1

LIMITS-1

RETENTION / DEDUCTIBLE-1

RETROACTIVE DATE-1

CURRENT CARRIER-2

EXPIRATION DATE-2

ANNUAL PREMIUM-2

LIMITS-2

RETENTION / DEDUCTIBLE-2

RETROACTIVE DATE-2

SECTION III - LOSS EXPERIENCE

(Explain any “Yes” responses, including corrective actions and damages incurred on the ADDITIONAL INFORMATION page below):

1. During the past three (3) years whether insured or not, have you sustained any losses due to unauthorized access, unauthorized use, virus, denial of service attack, electronic media liability, data breach, data theft, fraud, electronic vandalism, sabotage or other similar electronic security events?

Yes

2. Within the past three (3) years, have you experienced any network related business interruption exceeding eight (8) hours other than planned maintenance?

Yes

3. During the last three (3) years, has anyone alleged that you were responsible for damage to their computer system(s) arising out of the operation of Applicant’s computer system(s)?

Yes

4. During the last three (3) years, have you received a complaint or other proceeding (including an injunction or other request for non-monetary relief) arising out of intellectual property infringement, copyright infringement, media content, or advertising material?

Yes

5. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a lawsuit against you alleging invasion of, or interference with rights of privacy, or the inappropriate disclosure of personally identifiable information (PII)?

Yes

6. During the last three (3) years, have you been the subject of an investigation or action by any regulatory or administrative agency for privacy-related violations?

Yes

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