| PLEASE ANSWER THESE QUESTIONS TO DECIDE IF THIS PROGRAM IS RIGHT FOR YOU |
- Our Firm's total revenues for the past year and projected
revenues for the upcoming year are less than $750,000 annually.
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Yes No |
- Our revenues emanating from the U.S.A. are less than 35% of total revenues.
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Yes No |
- All of our firm’s physical premises are located in Canada.
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Yes No |
- Our firm has been in business for a minimum of two years OR each of our principals has a
minimum of 5 years industry experience.
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Yes No |
- Our firm has been "claims free" for the past 5 years. "Claims free" means no claims that would
have been covered by the proposed insurance. If in doubt, complete the CLAIMS INFORMATION
section that forms part of this application.
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Yes No |
- For contracts exceeding $50,000 in value, our firm will always require customers to sign written
agreements outlining the scope of services that we will provide.
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Yes No |
- We can confirm that NONE of our firm’s products or services have end use applications in the
following areas:
- Aerospace
- Air Traffic Control
- Internet Access Service Provision (ISP, ASP)
- Life Sustaining Medical
- Artificial Intelligence Systems
- Medical Diagnostic
- Credit Card Processing
- Mission Critical Systems
- Data/Systems Security
- Nuclear
- Hardware Design or Manufacturing
- On-line Application Service Provision
- Funds Transfer
- Robotics
- Industrial Process Control
- Web Hosting
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Yes No |
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| CONTACT
INFORMATION |
| Surname: * |
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First Name: |
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| Address: |
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| Telephone: |
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| E-mail: * |
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| City: |
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| Province: * |
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Postal Code: |
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| FIRM INFORMATION |
| Firm Name: |
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| Firm established in: yyyy |
| Total Revenues for the last 12 months (C$) |
Total anticipated revenues for the next 12 months: (C$) |
| Total Revenues emanating from the U.S.A.: |
Last 12 months: %
Next 12 months: % |
| The following is a description of our practices that best describes the majority of our services: |
| What is the worst thing that could happen to our customers' operations if our products or services were to fail or not meet their expectations?: |
| PREVIOUS ERRORS & OMISSIONS INSURANCE |
| Have you ever previously purchased professional or errors and omissions liability insurance? |
Yes No |
| If yes, please provide the following details: |
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Insurer: |
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Policy Period: |
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Retroactive Date: |
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Expiring Premium: |
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Limit: |
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Deductible: |
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| LIMITS OF LIABILITY |
Please indicate the limit(s) for which quotes are required:
- $500,000 per claim/$500,000 Aggregate
- $1,000,000 per claim/$1,000,000 Aggregate
- $2,000,000 per claim/$2,000,000 Aggregate
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| KNOWLEDGE OF PRIOR ERRORS & OMISSIONS OR CLAIMS |
| Are you aware of any error, omission, negligent act, unresolved contract job dispute or circumstance(s) that may result in a claim being made against you? |
Yes No |
| Has any claim, as would be covered by the proposed insurance, been made against you in the last five years? |
Yes No |
| If the answer to either of the two questions above is “yes”, please provide details below, including dates, names, amount claimed, nature of claim, total amounts paid, reserves and insurer(s) involved. |
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