techPRO

Company Name:
Street Address:
Town:
State:
ZIP:
Description of Business:
Do you currently have insurance?			Yes No
Years in Business:			Less Than One 1-3 Years 3-5 Years Over 5 Years
Do you desire Professional Liability?		Yes No
Property Coverage: (Complete if needed)
Location # :			One Location Only Location #1 Location #2 Location #3 Location #4 Location #5 Location #6 Location #7 Location #8 Location #9 Location #10
Location Type:			Home Office Leased Office Unit Leased Free Standing Building Owned Free Standing Building Condominium Other
If Other, Please Describe:
Occupancy Type:			Owner Occupant Tenant Occupant
Fire Hydrants within 1000 Feet:			Yes No
Fire Station within 5 Miles:			Yes No
Sprinklers:			Yes No
Dead Bolts:			Yes No
Central Station Monitored Burglar Alarm:			Yes No
Central Station Monitored Fire Alarm:			Yes No
Building Age:			1 Year Old 2-5 Years Old 6-10 Years Old 11-40 Years Old Over 40 Years Old
Building Construction Type:			Frame Masonary with Wood Roof Masonary with Steel Roof Fire Resistive
Building Value (Enter $ Amount):
Contents Value (Enter $ Amount):
Computer Value (Enter $ Amount for Hardware & Software):
Deductible:			$250 $500 $1,000 $1,000+
Glass Coverage:			Yes No
Linear Feet (Enter #):
Sign Value (Enter $ Amount):
Are adequate records kept?			Yes No
Exterior Lighting Front & Back of Bldg:			Yes No
Over $1,000 cash kept on premises:			Yes No
Do you back-up information daily?			Yes No
Is the back-up kept off premises?			Yes No
Is your payment system secured?			Yes No
Do you regularly check for viruses?			Yes No
General Liability Coverage:
Number of Employees:
Additional Insured(s):			Yes No
Number Requested:
General Liability Limit:			$500,000 $1 Million
Umbrella Liability (If Desired):			$1 Million $2 Million $2 Million+
Number of Autos Legally Titled In Your Business Name:
Technical Underwriting Information:
Description of Operations/Services:
Square Footage of Office Space:
Number of Applicant's Principals:
Number of Applicant's Technical Staff (Excluding Principals):
Number of Applicant's Clerical/Administrative Staff:
Fiscal Year (e.g. Mo/Yr to Mo/Yr):
Domestic Gross Revenues (Enter $ Amount):
Current Year:
Next Year (Projected Estimate):
Last Year:
Foreign Gross Revenues (Enter $ Amount):
Current Year:
Next Year (Projected Estimate):
Last Year:
Are you designing software that involves any of the following:
Military /Nuclear:	Y2K Issues:			Robotics/Heavy Machinery:
Financial Institution:	Automated Quality Control:			Alarm Warning:
Remote Sensing Systems:	Temperature or Fluid Level Monitoring:
If yes, please explain in detail:
Claims Information:
Any Property Claims within 3 Years:			No Yes
If So, Describe (Include Pay Out):
Any Liability Claims within 3 Years (General or Professional):			No Yes
If So, Describe (Include Pay Out):
Are you aware of any potential claim or situation that may become a claim?			No Yes
If So, Describe:
Contact's Name:
Contact's Phone Number (Include Area Code):
Contact's Fax Number (Include Area Code):
Contact's E-Mail Address: