APPLICATION FOR CONTROL AND INFORMATION SYSTEM INTEGRATORS PROFESSIONAL LIABILITY

Transcription

1 James River Insurance Company and its Subsidiaries 6641 West Broad Street, Suite 300 Richmond, VA Application for Control and Information Systems Integrators Professional Liability PROFESSIONAL LIABILITY Division to or, Fax to APPLICANT S INSTRUCTIONS: 1. Answer all questions completely. Please attach extra sheets as required. Incomplete or illegible applications may be discarded. 2. Application must be signed and dated by the owner, partner, or officer not earlier than 45 days before the proposed effective date of coverage. 3. Please read the statements at the end of this application carefully. Thank you! APPLICATION FOR CONTROL AND INFORMATION SYSTEM INTEGRATORS PROFESSIONAL LIABILITY NOTICE: THE POLICY PROVIDES THAT THE LIMITS OF LIABILITY AVAILABLE TO PAY JUDGEMENTS OR SETTLEMENTS SHALL BE REDUCED BY DEFENSE EXPENSES, AND THAT DEFENSE EXPENSES SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT. PLEASE ATTACH THE FOLLOWING: Applicant s most recent annual report/financial statement 1. Applicant firm name: Telephone #: Contact Person: Fax#: Principal business address: City: State: Zip Code: address: Website: 2. Limits of Liability desired: $ each Claim or Related Claims $ aggregate for all claims 3. Deductible desired: $2,500 $5,000 $10,000 $25,000 Other 4. Applicant is: Individual Corporation Partnership LLC 5. Year established: If less than five years, please attach resumes of all principals. 6. Please describe in detail the professional services for which coverage is desired: A. Control System Integration: B: Other Business: 7. Please indicate the total annual gross revenues derived from the services described in Question 6 for the past three years and the projected revenues for the current year: YEAR REVENUE a) Current $ (estimated) b) $ c) $ JRAP0080 Page 1 of 6 James River Insurance Co. 2005

2 d) $ 8. For the revenue listed in Question 7, please indicate the approximate percentage derived from each of the following services: Hardware/Software % Panels/Stations % System Assembly % Commissioning/Training % Ongoing Support % Consulting % Project Management % Specification/Design % Development/Testing % 9. Please describe your largest project or installation or the cost of your most expensive product in the last year: Customer: Cost: Description 10. Describe any discontinued products or operations, including dates and reasons for discontinuance: 11. Do you use Subcontractors? Yes No 12. Do you require subcontractors to provide certificates of insurance for GL, E&O, Workers Compensation and Umbrella/Excess Liability? Yes No 13. Are you added to all Subcontractors coverage as an Additional Insured? Yes No 14. Are all products or services sold with a standard written contract addressing warranties and liabilities? Yes No 15. Has legal counsel reviewed all contracts? Yes No 16. Does each contract include: a. Disclaimer of all other warranties not shown specifically in the contract? Yes No b. Disclaimer of warranty for merchantability? Yes No c. Disclaimer of warranty of fitness for a particular purpose? Yes No d. Exclusive remedy of repair or replacement at insured s option? Yes No e. Limitation of liability to cost of product or service? Yes No f. Disclaimer of liability of consequential or incidental damages? Yes No g. Obligation to provide regular upgrades and service? Yes No 17. Do your contracts with distributors contain indemnification wording? Yes No 18. Has legal counsel reviewed all distributor contracts? Yes No 19. Do you have any contracts with suppliers of materials or services that are included in your products or services? Yes No JRAP0080 Page 2 of 6 James River Insurance Co. 2005

3 20. Do you require distributors to provide certificates of insurance for E& O liability? Yes No 21. Is the Applicant controlled or owned by or associated or affiliated with, or does it own, any other firm or business enterprise? Yes No If Yes, please attach an explanation and indicate if any services described in Question 6 are provided to such firm or business enterprise. 22. During the past five years, has the Applicant s name been changed, or has the Applicant purchased, merged or consolidated with any other business or has the Applicant been purchased? Yes No 23. Are any changes in the nature or size of the Applicant s business anticipated over the next 24 months? Yes No Changes in size of less than 25% need not be explained. 24. Please indicate the number of: a) Principals, partners, officers and professional employees directly engaged in providing services to clients: b) All other (non-professional/clerical) employees: 25. Please list professional associations to which the Applicant belongs: 26. Please provide the following: NAMES OF ALL PARTNERS, PRINCIPALS AND KEY APPLICANT EMPLOYEES PROFESSIONAL QUALIFICATIONS or DESIGNATIONS # OF YEARS IN PRACTICE 27. Has the Applicant provided services to any governmental entities? Yes No 28. Does any director, officer, employee, or partner of the Applicant serve on the board of directors of any client of the Applicant? Yes No 29. Does the Applicant use a written contact with the clients? In all cases Sometimes Never Please attach samples copies of all types. JRAP0080 Page 3 of 6 James River Insurance Co. 2005

4 30. Does the Applicant subcontract work to others? Yes No 31. Does the Applicant have a written procedural manual for employees to follow? Yes No 32. Does the Applicant have procedural literature? Yes No If Yes, please attach an explanation 33. Does the Applicant have a formalized training program for newly hired employees? 34. Does your due diligence process include: Yes No Research of prior errors, incidents or customer complaints? Yes No Notification to current carrier of any discovered errors, incidents or customer complaints? Yes No Research of prior litigation? Yes No Review of outstanding contracts? Yes No Review and consideration of existing agreements for maintenance, service, or upgrades? Yes No 35. Please describe your Quality Assurance program: Quality Assurance Coordinator? Written QA Program? ISO Certification? Quality Assurance Audits? Field Performance or Reliability Data Maintained? 36. Product Recall: Name: Engineer in charge Last Revision to Program? How long are records retained? Certification Level? Describe info maintained. Product Recall Coordinator? Written Product Recall Program? Recall Program Audit? Prior Product Recalls? Name: Last Revision to Program? How long are records retained? If Yes, attach details. 37. Do you have a Formal Customer Acceptance Procedure? Yes No 38. Describe Procedures for notifying customers of problems: JRAP0080 Page 4 of 6 James River Insurance Co. 2005

5 39. Do you now or have you ever provided consulting services related to identifying or correcting data related to code problems? Yes No (if yes, please attach details.) 40. Has any errors and omissions or professional liability insurance ever been declined or cancelled? Yes No 41. Is any errors and omissions or professional liability insurance currently in force? Yes No If Yes, please indicate: From To Insurance Company Limits of Liability Deductible Premium a. Retroactive date of current policy: b. Has the firm ever purchased an extended reporting period endorsement ( tail coverage )? Yes If Yes, please advise effective date and expiration date: No 42. Does any director, officer, employee or partner of the Applicant have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim? Yes No 43. Has the Applicant or any director, officer, employee or partner of the Applicant ever been the subject of disciplinary action as a result of professional activities? Yes No 44. Please attach a list and status of all errors and omission claims made during the past five years against the Applicant or any director, officer, employee or partner of the Applicant. If none, please check here: None NOTICE TO APPLICANT: The coverage applied for is solely as stated in the policy. The policy is issued on a CLAIMS MADE AND REPORTED basis, it provides coverage only for those claims that are first made against the insured during the policy period unless the extended reporting period option is exercised in accordance with the terms of the policy. The Insurer will rely upon this application and all such attachments in issuing the policy. If the information in this application or any attachment materially changes between the date this application is signed and the effective date of the policy, the Applicant will promptly notify the Insurer, who may modify or withdraw any outstanding quotation or agreement to bind coverage. JRAP0080 Page 5 of 6 James River Insurance Co. 2005

6 It is a crime for any person to knowingly provide or facilitate in providing any false, incomplete, or misleading information to any insurance company. Such acts can result in fines, penalties, imprisonment and loss of insurance coverage. WARRANTY: I warrant to the Insurer, that I understand and accept the notice stated above and that the information contained herein is true and that it shall be the basis of the policy of insurance and deemed incorporated therein, should the Insurer evidence its acceptance of this application by issuance of a policy. I authorize the release of claim information from any prior insurer to James River Insurance Company and its Subsidiaries, 6641 West Broad Street, Richmond, VA Applicant s Name: Signature Title: Date: JRAP0080 Page 6 of 6 James River Insurance Co. 2005