Philadelphia Insurance Companies, Inc.
One Bala Plaza, Bala Cynwyd, Pennsylvania 19004 PHONE: 800-899-1399 FAX: 800-652-4161
PROFESSIONAL LIABILITY FOR SPECIFIED PROFESSIONS TECHNOLOGY CONSULTANTS SUPPLEMENT
Instructions: A. If more space is required to answer a question, continue on applicant's letterhead. B. This supplement must be signed and dated by a principal, partner, officer of the prospective insured's organization and will be attached to the policy, should one be issued.
Please list and provide a brief discription of your primary software and service applications. (i.e. payroll, fund transfer, educational , etc.)
Please indicate the percentage of your annual revenue from the last fiscal period involving: B. training and education records management / retreival package software installations minor hardware installations hardware maintenance / service graphics / presentation materials hardware / software pass-thru sales (sold at cost) % % % % % % % % D. % computer security/virus services % % electronic bulletin board/chat room service % turnkey % e-mail services % hardware / web-site design/construction % % content provider services % internet service provider (ISP) % TOTAL (C) % internet advertising % domain name registration % TOTAL (D) TOTAL (A) % + TOTAL (B) % + TOTAL (C) % + TOTAL (D) %* = 100% %* hardware / software sales equipment evaluation and selection EDP audit "needs" evaluations % % % % TOTAL (B) %
TOTAL (A) C. custom software development system design installations software manufacturing research and development
*If any percentage in D please complete questions 4 – 10. 3. Does the applicant provide any services other than those services listed above in 2? If yes, provide details on a separate sheet. Yes No
Have you ever received a complaint concerning Internet Services relevant to:
P I-P LSP -(04/20 02)
Libel or Slander Trademark Infringement Invasion of Privacy Copyright Infringement Inaccurate Information 5.
Yes Yes Yes Yes Yes
No No No No No
How do you respond to such complaints and in what time frame?
Does in-house counsel review the items listed in #4 above?
What measures are taken to determine that Domain names you use or register does not infringe upon another’s copyright or trademark?
How do you prevent computer viruses from being transmitted from or to the work you complete?
Does the web-sites you develop or Internet Services you provide involve selling any products over the Internet (e-commerce)? If yes, are credit card transactions conducted? Yes No Please list the web-site addresses of the top 3 Internet Services projects completed last year or expected this coming year. www. www. www.
Please attach the following sample contracts, where applicable: a) EDP and Consulting Agreement. b) Software Licence Agreement. c) Distribution Agreement with software and / or hardware manufacturer. d) Sales agreement.
THIS COMPUTER CONSULTANTS' SUPPLEMENTAL APPLICATION IS ATTACHED TO AND FORMS PART OF THE PROFESSIONAL LIABILITY FOR SPECIFIED PROFESSIONS APPLICATION. THIS SUPPLEMENT IS SUBJECT TO THE SAME PROVISIONS CONCERNING REPRESENTATIONS MADE IN THE BASIC APPLICATION. ____________________ NAME ___________________________ SIGNATURE ___________________________ TITLE ____________ DATE
P I-P LSP -(04/20 02)