QUICKQUOTE ONLINE APPLICATION Technology Company Errors and Omissions (E&O)             Agent Name: Agency Name:   Mailing Address:       City:   State:   Zip/Postal:   Phone Number: Fax: Email Address: Please enter this information as you would wish it to exactly appear on the insurance policy. This application form is for a "Claims Made" policy Applicant Information Back up Contact Person       Applicant Contact Name: Applicant Company Name:   Mailing Address:       City:   State:   Zip/Postal:   Phone Number: Fax: Email Address: Applicant Website Address (URL):   If you have an existing complete application form, you may skip to the bottom of this document and push the "Get Quote" button at the bottom. Please email the application to:  jkelly@walkertaylor.com . We will contact you if additional information is required.  If you do not have an application already completed, please continue to fill out this form, and click on “submit“ button when finished. Application Form Corporate Structure: How many employees: Gross Revenues for last year: Estimated Current Year Revenues: Year Business Established:   Focus of Business Receipts % Focus of Business Receipts % Application Service Provider Game Developer Commercial On-Line Services Hardware Systems Installation Computer Related Training Hardware Systems Maintenance Consulting on Hardware Hosting Web Pages Consulting on Software Internet Access Provider Content Provider for Web Page/Forum Internet Service Provider Custom Software Development Packaged Software Development Data Processing and Entry Software Systems Installation Electronic BBS Software Systems Maintenance Forum Manager Web Page Development File Transfer Site(FTP) Web Page Maintenance/Updates Forum/Content Channel Other revenue sources-   Describe other sources of income not listed above: Detailed Description Of Business :   Are any significant changes in the nature or size of the Applicant's business anticipated over the next 12 months and/or have there been any such changes in the past 12 months? Yes No Does the Applicant have any contracts valued at USD 1,000,000 or above? Yes No Does the Applicant maintain and use written contracts with all of their clients? Yes No Do you have a website/online services or provide such services to third parties? Yes No Do you have a policy for removing controversial material (libellous, slanderous, etc) from your On-line Service, including On-line Services provided to Third Parties? Yes No Do you have a policy for removing infringing material (copyright, trademark, etc) from your On-line Service, including On-line Services provided to Third Parties? Yes No Are firewalls used to prevent unauthorised access connections from internal networks and computer systems to external networks? Yes No Are anti-virus procedures used on desktop and mission critical servers? Yes No Are backup and recovery procedures documented for all mission critical systems? Yes No Do you develop and/or provide mission critical systems? Yes No Is the nature of your market, products or services: ----- a) Adult Related Yes No ----- b) Auction Related Yes No ----- c) Aviation Yes No ----- d) Domain Name Registration Yes No ----- e) Engineering Yes No ----- f) Entertainment (i.e. MP3, downloading music, video etc) Yes No ----- g) Financial Trading and/or Fund Transfer Yes No ----- h) Hardware Manufacturing Yes No ----- i) Lottery Related Yes No ----- j) Medical Yes No ----- k) Offline Publishing/Printing Yes No ----- l) Process Control Yes No ----- m) Religious Yes No Describe any current insurance maintained. The Retroactive Date below means the policy inception date for which the most recent main form application was attached. Coverage Currently Maintained Insurance Carrier Limit Deductible Retroactive Date Technology E&O Yes No Media Coverage Yes No Breach of Network Security Yes No Misc E&O Yes No Date Quote Needed by   Does the Applicant organisation currently maintain a policy, covernote or certificate with any Underwriter at Lloyd's of London in respect of the above coverages: Yes No Has the Applicant organisation ever been the subject of, or involved in, any disciplinary or regulatory proceeding by any professional body or association or any regulatory or governmental agency?: Yes No Does any director, officer, employee or partner of the Applicant organisation have knowledge or information of any act, error, or situation which might reasonably be expected to give rise to a claim?: Yes No Has the Applicant organization been party to any lawsuit or other legal proceeding within the past five years? Yes No Has any claim or allegation of a nature for which coverage is now being sought been made against the Applicant organisation or any of its directors, officers, partners or employees in the last five years, whether covered under any preceding policy or not?: Yes No Has any errors and omissions or professional liability insurance ever been declined or cancelled? Yes No   Please provide any other important information you wish to communicate to us:

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