Technology Professional Package Application

I. INSTANT QUOTE INFORMATION
Applicant Name
Location Address
Street Address
Zip Code
State
City
 
Web Address
Primary contact name
Primary contact phone
Email Address of primary contact
Description of Operations
Revenues
What is the total number of employees? (includes owners, principals and partners)
Please check each one that applies from the following list of classifications
Cloud Providers/Application service provider/software as a service
What percentage of receipts are derived from this?
Consulting/training/project management/staffing
Data or records storage/retrieval/back-up
What percentage of receipts are derived from remote data back-up?
Database administration
Hardware evaluation/selection/maintenance
Hardware manufacturing
What percentage of receipts are derived from this?
Help desk
Internet service provider, search engine or online publishing/sales
Network or computer security
What percentage of receipts are derived from this?
Software development/installation/sales
If developing packaged software, please provide number of licenses:
Systems, network or audio-visual evaluation/design/cabling/support
Web design/development/hosting or search engine optimization
Other
Please provide a short description of the services you provide in the box below:
Has there been prior Errors and Omissions liability coverage?
What is the earliest date of continuous Errors and Omissions liability coverage? (Referred to as a Retroactive Date on the declarations page of your policy)
Retail Agent Information:
Retail Agency
Retail Agent Contact
Retail Agent Contact Email

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