Chubb EIT Small Business Proposal 500k 5m AIIA1 by In3PZQE6

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									              CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED
              A.B.N. 69 003 710 647, AFS Licence No. 239778
 C H U B B    Locked Bag 13, Australia Square, NSW, 1215, Australia
              L36, Australia Square, 264-278 George Street, Sydney, NSW, 2000, Australia




              INFORMATION & NETWORK TECHNOLOGY
                     LIABILITY INSURANCE POLICY
                2005 SMALL BUSINESS PROPOSAL FORM
                                                     STATUTORY NOTICES


Throughout this Proposal, “you”, “your” or “yours” refer to the                SUBROGATION
Proponent specified in Part (1) of the Proposal. “We”, “us” or
                                                                               You may prejudice your rights with regard to a claim if,
“our” refer to Chubb Insurance Company of Australia Limited.
                                                                               without prior agreement from Chubb, you make agreement with
                                                                               a third party that will prevent Chubb from recovering the loss
                                                                               from that, or another party.
YOUR DUTY OF DISCLOSURE
Before you enter into a contract of insurance with Chubb                       Your policy contains provisions that either exclude Chubb from
Insurance Company of Australia Limited (“Chubb”), you have                     liability, or reduces Chubb’s liability, if you have entered into
a duty, under the Insurance Contracts Act 1984 (Cth.), to                      any agreements that exclude your rights to recover damages
disclose to us every matter that you know, or could be                         from another party in relation to any loss, damage or
reasonably expected to know, is relevant to our decision                       destruction which would allow you to sustain a claim under
whether to accept the risk of the insurance, and if so, on what                this policy.
terms.
                                                                               CHANGE OF RISK OR CIRCUMSTANCES
You have the same duty to disclose these matters to us before                  It is vital that you should advise us of any departure from your
you renew or change the contract.                                              “normal” form of business (ie. that which has already been
Your duty, however, does not require disclosure of any matter:                 conveyed to Chubb). For example, acquisitions, changes in
-        that diminishes our knowledge;                                        location or new overseas activities.
-        that is of common knowledge;
-        that we know, or in the ordinary course of our                        CONFIDENTIALITY
         business as an insurer, ought to know; or                             Chubb acknowledges that this proposal may contain
-        as to which compliance with the duty of disclosure is                 information of a commercially sensitive and confidential
         waived by us.                                                         nature. We undertake to restrict use of this information to
NON-DISCLOSURE                                                                 matters related to the coverage sought and will not disclose
                                                                               this information to other parties.
If you fail to comply with your duty of disclosure we may be
entitled to reduce our liability under the contract in respect of a            COMPLETING THE PROPOSAL
claim or may cancel the contract. If your non-disclosure is
fraudulent we may also have the option of avoiding the contract                In completing this proposal and questionnaire:
from the beginning.
                                                                               -           Please read all the “Statutory Notices” before
UTMOST GOOD FAITH                                                                          completing this proposal form.
                                                                               -           Please answer all questions in full leaving no blank
Every insurance contract is subject to the doctrine of utmost                              spaces.
good faith which requires that parties to the contract should act              -           If you have insufficient space to complete any of
toward each other with the utmost good faith. Failure to do so                             your answers, please attach a separate signed and
on your part may prejudice any claim or the continuation of                                dated sheet and identify the question number
cover provided by the Chubb.                                                               concerned.
CLAIMS MADE POLICY                                                             -           Some sections of this proposal will not apply to your
                                                                                           firm. Where this is the case please mark not
This policy provides insurance on a “claims made” basis, which                             applicable (N/A).
means that claims first advised to you (or made against you)
during the period of insurance are insured, irrespective of when
the incident causing the claim occurred.
NOT A RENEWABLE CONTRACT
Insurance under this policy will terminate at expiry of the
Period of Insurance specified in your policy document. If you
wish to effect similar insurance for a subsequent period, it will
be necessary for you to complete a new proposal form prior to
the termination of the current policy so that terms of insurance
and quotation/s can then be developed for your consideration.



Chubb INT Liability Policy Small Business Proposal Form 2005.08                                                                          Page 1
                CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED
                A.B.N. 69 003 710 647, AFS Licence No. 239778
C H U B B       Locked Bag 13, Australia Square, NSW, 1215, Australia
                L36, Australia Square, 264-278 George Street, Sydney, NSW, 2000, Australia



Some sections of the application will not apply to your firm. Where this is the case, please mark “not applicable” (N/A).

Before continuing, please attach copies of:

Copies of your standard and largest sales, service and license contracts or agreements
Please list your web site addresses:

1.      General Information

(i)       Name of Insured and ABN (include names of all subsidiary or affiliated companies to be insured):


(ii)      Head Office Address:

(iii)     Date Firm Established?
(iv)      How many locations do you currently own, lease or operate from?
(v)       Total number of employees?

2.      Limits of Insurance

Professional Liability                         $1m                   $2m                     $5m            $10m                   Other
(Coverage A)
General Liability                              $5m                                  $10m                              Other


3.      Deductible

Professional Liability                         $5,000                $10,000                 $20,000        $50,000                Other
(Coverage A&B)

General Liability                              $1,000                                              Other


4.      Worldwide Revenue or Turnover including Licensing fees:

Territory                                      Current Year                                        Forecast Next Year

Australia & New Zealand                        $                                                   $

USA & Canada                                   $                                                   $

Other, please specify                          $                                                   $

Total                                          $                                                   $

5.      Please provide the approx. percentage of your revenue applicable to each State, Territory and overseas.

      NSW              VIC              QLD               SA               WA                ACT           NT            TAS            O/S
            %                %                %                %                %                  %            %              %              %

6.      Mergers or Acquisitions or Divestitures:

Have you sold or purchased any companies during the past year?                                                  Yes                No
       If yes, please provide detail:
       Did you Purchase?                                                                                        Assets             Liabilities




Chubb INT Liability Policy Small Business Proposal Form 2005.08                                                                            Page 2
                CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED
                A.B.N. 69 003 710 647, AFS Licence No. 239778
C H U B B       Locked Bag 13, Australia Square, NSW, 1215, Australia
                L36, Australia Square, 264-278 George Street, Sydney, NSW, 2000, Australia



7.     Types of Products/Services

(i)     In your own, words, please provide a detailed description of your main operations: Eg Pre-packaged
        software developer, developing applications for website owners, operators and developers. Applications allow
        customers to view documents and leave feedback messages.




(ii)    Please provide the percentage of your annual revenue or turnover split among the following:-

Computer programming services or computer software systems analysis and design                                                  %

Development and sale of pre-packaged software (own developed)                                                                   %

Reseller of third party Hardware and Software                                                                                   %

Computer or network system integration, computer systems turnkey vendor or computer systems                                     %
value added reseller
Computer data preparation and processing services                                                                               %

Information Retrieval Services                                                                                                  %

Facilities Management or Computer Outsourcing / Hosting                                                                         %

Computer Maintenance and Repair                                                                                                 %

Manufacturer of Electronic Computers/ Peripheral Equipment/ Communication Equipment                                             %

Placement of permanent or temporary staffing of computer programmers or other IT staff who                                      %
will work at the direction of your customer

ISP and other Telecommunications Services                                                                                       %

Other, please explain                                                                                                           %


8.     Application of Products/Services

(i)         Number of different products currently supported or                              0 to 3   4 to 6         more than 6
            distributed:
(ii)        Is the end use of the product or service you provide involved in any of the                            Yes         No
            following?
                 Medical industry devices or applications                                                If yes, please provide detail:
                 Fire, Security or other emergency applications
                 Privacy Applications
                 Oil, Gas/Power/Nuclear Energy applications
                 Manufacturing Process Control systems
                 Aerospace/defence applications
                 Enterprise Resource Planning (ERP)/ Supply Chain Mgt (SCM) or
                  Customer Relationship Mgt (CRM)
                 Financial Banking or Trading Systems




Chubb INT Liability Policy Small Business Proposal Form 2005.08                                                                    Page 3
                CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED
                A.B.N. 69 003 710 647, AFS Licence No. 239778
C H U B B       Locked Bag 13, Australia Square, NSW, 1215, Australia
                L36, Australia Square, 264-278 George Street, Sydney, NSW, 2000, Australia




(iii)       Please select your primary                      Home Users / Small Business           Commercial           Government
            customer base:                                   (Less than 7 employees and
                                                           operate from a single location)


(iv)        What would be the largest                                No Disruption             Minor or Delayed   Major or Immediate
            financial and business impact on
            your customer from a failure of
            any of your products or services?

(v)         Is more than 25% of your total revenue derived from a combination of the                           Yes               No
            following services:
                  Develop websites for customers
                  Provide internet access (for example ISP)
                  Host customers computers or websites
                  Advertising revenue

(vi)        Does your website, operations or products offer any of the following?                              Yes               No
                  Business to Consumer e-commerce transactions or exchanges
                   (Companies like e-tailers whose primary means of revenue generation
                   involves selling services to customers)
                  Business to Business e-commerce transactions or exchanges (Companies
                   like electronic distributors or wholesalers whose primary means of
                   revenue involves selling products or services to another business)

(vii)             Does your website, operations or products offer any of the following?                       Yes               No
                  Auction sites, stock or commodity trained, or casino gaming
                  Downloadable music, videos or additional types of materials
                   owned/copyrighted by others
                  Children focused content (Sites dedicated to entertaining children that
                   may have features that include chat rooms, downloadable games and
                   other materials, and sell a variety of consumer goods).
                  Adult content- pornographic sites


  9.    What percentage of your revenue is derived from consulting and / or custom software development?
  (a) 0-10%                         (b) 11-30%                    (b) 31-40%                 (b) 41-50%              (e) 51% +            0-10%

If you answered (a) please go to question 10, otherwise complete question 9(i) to 9(v).

9 (i)       Please select the type of consulting that best describes your business activities:

Type 1:                     Work related to the sale or service of your hardware, software, I/T systems or I/T
                             networks
                            Work you do which is related to hardware, software, IT systems or IT networks
                             which you sell or distribute for others.

Type 2:                     Miscellaneous IT work done at the direction of others
                            Data processing or Data Entry
                            Programmers working at the direction of others
                            I/T help desk support staffing or outsourcing

Type 3:                     Client server applications development
                            Software engineering for desktop and other non-mission critical projects
                            System integration if the work includes value added reselling and is done for office
                             automation specific desktop functions, specific task automation or specific tasks at
                             a process level.


Chubb INT Liability Policy Small Business Proposal Form 2005.08                                                                  Page 4
              CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED
              A.B.N. 69 003 710 647, AFS Licence No. 239778
C H U B B     Locked Bag 13, Australia Square, NSW, 1215, Australia
              L36, Australia Square, 264-278 George Street, Sydney, NSW, 2000, Australia




Type 4:                 Customer Relationship management (CRM)
                        Enterprise Resource Planning (ERP)
                        Supply Chain Management (SCM)
                        Enterprise Application Integration (EAI)
                        Manufacturing Execution Systems
                        Integrated Manufacturing Solutions
                        Production Scheduling
 9 (ii)       Of the custom software development you perform, is the contract or purchase                           Yes              No
              order modified if interim changes are made and signed by both parties
 9 (iii)      Of the custom software development you perform, is the contract or purchase                           Yes              No
              order signed again at the final acceptance of the project or upon delivery of
              the products?
 9 (iv)       Are your products/solutions fully tested prior to production release?                              Yes        No           N/A
 9 (v)        Do you consult with intellectual property lawyers before you release new                           Yes        No           N/A
              software products?

10. Contract Review/ Licensing Agreements

 (i)          Do you perform legal review of all standard contracts, agreements and                                 Yes             No
              marketing materials prior to release?
 (ii)         Do you ever negotiate contracts or agreements in which you accept liability                           Yes             No
              for consequential damages?
 (iii)        Do you have a standard signed contract or purchase order with every                                   Yes             No
              customer?
 (iv)         Do all your contracts or agreements limit your liability to the cost of your                          Yes             No
              product or service?
 (v)          What is the size of your average              $0- $100,000           $100,001-$250,000                        $250,001 +
              contract/product cost?
 (vi)         What is the size of your largest                     $0- $100,000              $100,001-       $250,001 -       $500,001 +
              contract/product cost:                                                         $250,000         $500,000

 (vii)        If the size of your largest contract is greater than $500,000, please provide information for your two largest
              contracts, purchase orders or agreements.
  Customer Name                   Size of           Length         Development             Licence Fees    Maintenance      Type of Product
                                Contract ($)       (Months)         Cost * (%)                 (%)        Cost / Fees (%)      / Service
                            $                                                   %                  %               %

                            $                                                   %                  %               %
* Development cost includes software development, customisation, enhancements, systems integration etc

11. Subcontractors, Vendors, Independent Contractors and OEMs

Do you use subcontractors?                                                                                          Yes              No

If yes, (a) Are contracts established?                                                                              Yes              No
        (b) Do the contracts indemnify and hold you harmless?                                                       Yes              No

12. Quality Control/System Development Procedures

(i)        Do you have written quality control procedures:                                                          Yes              No

(ii)       Do you employ the following quality control procedures:
            Provide at least two forms of product support
                                                                                                                    Yes              No
            Maintain a list of customers for follow-up contract
            Maintain logs on problems and downtime
Chubb INT Liability Policy Small Business Proposal Form 2005.08                                                                      Page 5
             CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED
             A.B.N. 69 003 710 647, AFS Licence No. 239778
C H U B B    Locked Bag 13, Australia Square, NSW, 1215, Australia
             L36, Australia Square, 264-278 George Street, Sydney, NSW, 2000, Australia




If you manufacture or have a third party manufacture on your behalf, please complete the following question
(iii)    Do you, or a third party manufacturing on your behalf, have quality control
         procedures such as:
             Formalised, written quality control plans
                                                                                                     Yes              No
             Production design sign off Acceptance and sign off procedures for
              statements of work or contracts
             Prototype development protocols
             Batch testing

13. VIII Historical Information

Have you ever experienced any of the following:
Any contract dispute alleging non-performance of your product or service, including
suits, potential suits or complaint letters                                                          Yes              No
Any customers who have withheld payments due to a contract dispute within the past
three years                                                                                          Yes              No
Any dispute where you have been named that involves copyright, patent or trademark
infringement                                                                                         Yes              No
Has any insurance company ever declined to write Professional Indemnity insurance
for you?                                                                                             Yes              No
Are you aware of any act, error or omission, unresolved contract dispute or any other
circumstance, which may reasonable be expected to result in a claim or an allegation of              Yes              No
non performance or delay being made against you?
For each instance answered Yes above, please explain:

Do you currently purchase Errors or Omissions or Professional Liability coverage?                    Yes              No
      If yes, please list:

         Current Insurer:
         Term:
         Limit:                        $
         Deductible:                   $
         Retroactive date:                      /         /



FALSE INFORMATION
Any person who, knowingly and with the intent to defraud any insurance company or other person, files a
proposal for insurance containing any false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
                                                          DUTY OF DISCLOSURE
Is there any other matter you should advise us of in accordance with your duty of disclosure? If yes, comment in space
provided below.
                                                              DECLARATION
1.      (I/We)         have read the Important Notices at the head of this Proposal.
2.      (I/We)       declare that the answers above are true and correct and I/We have discharged my/our duty of disclosure.
3.      (I/We)       agree that the person completing this Proposal wholly or in part does so as my/our agent and not that of
        Chubb Insurance Company of Australia Limited.

  DATE                 /         /                  PROPOSER’S SIGNATURE

  TITLE                                             NAME



Chubb INT Liability Policy Small Business Proposal Form 2005.08                                                        Page 6
            CHUBB INSURANCE COMPANY OF AUSTRALIA LIMITED
            A.B.N. 69 003 710 647, AFS Licence No. 239778
C H U B B   Locked Bag 13, Australia Square, NSW, 1215, Australia
            L36, Australia Square, 264-278 George Street, Sydney, NSW, 2000, Australia


Please attach copies of:
Copies of your standard and largest sales, service and license contracts or agreements.
WHY TECHNOLOGY COMPANIES CHOOSE CHUBB
• Proven heritage in insuring technology companies around the world;
• Underwriters have in-depth knowledge of the technology sector and the risks faced;
• Worldwide network of more than 130 offices in 32 countries to provide local cover for multinational operation exposures;
• Consistently high ratings for financial strength assure our ability to pay claims now and in the future;
• Award-winning claim service helps customers back into business quickly after a covered loss;




Chubb INT Liability Policy Small Business Proposal Form 2005.08                                                              Page 7

								
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