Abco Insurance Agency Insurance Quote Form

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PLEASE NOTE: THIS APPLICATION IS FOR INSURANCE THAT IS WRITTEN ON A "CLAIMS" MADE BASIS AND PROVIDES COVERAGE FOR THOSE "CLAIMS" WHICH ARE THE RESULT OF "WRONGFUL ACTS" HAPPENING SUBSEQUENT TO THE RETROACTIVE DATE STATED ON THE DECLARATIONS AND WHICH ARE FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD. DEFENSE COSTS REDUCE THE LIMIT OF INSURANCE AND ARE SUBJECT TO A DEDUCTIBLE. THROUGHOUT THIS APPLICATION THE TERM "YOU" MEANS THE APPLICANT IDENTIFIED IN PART I BELOW.

I. GENERAL INFORMATION - to be completed by all applicants
   
   
Name of Applicant (as it should appear on Policy)
Street Address:
City, State, Zip Code:

Business Type:
 Corporation  Partnership  Joint Venture  LLC
Ownership Structure:
 Public  Private  Not-for-profit
Year Established:
Number of Employees:
II. COVERAGES – to be completed by all applicants
   
   
1. Select each Coverage and indicate the Limit of Liability and Retention for which you are applying:
   
Coverage Limit of Liability Deductible
 Technology Errors & Omissions
 Media Liability
 Network Security & Privacy Injury Liability
 Privacy Regulation Proceeding Sublimit
 Privacy Event Expenses Sublimit
 Extortion Sublimit
   
2. What is the proposed effective date of coverage? (mm/dd/yyyy):
   
3. Do you currently have a policy in-force providing any of the above coverages?
   
Coverage Technology E&O Media Liability Network Security/Privacy Injury
Carrier
Policy Period
Limit of Liability
Retention
Claims Made or Occurrence
Retroactive Date
Premium
   
   
III. REVENUE – to be completed by all applicants
   
   
1. Indicate on what date your fiscal year ends: /
   
2. Indicate your Gross Annual Revenue for the following twelve (12) month fiscal time periods:
   
Revenue Split Prior Fiscal Period Current Fiscal Period Next Fiscal Period
Domestic
Foreign
Total
   
   
IV. SERVICE/PRODUCTS ALLOCATION/DESCRIPTION OF OPERATIONS –
to be completed by all applicants
   
   
1. Description of Operations:  
   
Technology - Software & Services % Technology - Hardware & Equipment %
Application Service Provider Computer System Manufacturing
Cloud Computing - private    
Cloud Computing - public    
Co-location Services Computer Peripherals Manufacturing
Custom Software Development Electronic Component Manufacturing
Data Processing & Outsourced Services Instrument Manufacturing
Domain Name Registration Office Electronics (other than computers) Manufacturer
E-Mail Services Recycling/Destruction of hardware
Internet Service Provider Telecommunications Equipment Manufacturing
IT Consulting Other (describe)
IT Staff Augmentation Distribution %
Managed IT Services Computer Equipment & Software Distribution
Network Security Software and Services Electronic Component Distribution
Outsourcing Instrument Distribution
Pre-Packaged Software Development/Sales Other (describe)  
System Design and Integration Telecommunication Services
Technical Support/Repair & Maintenance Local & Long Distance Service Providers
Training & Education Telecommunications Consulting
Value-added Reseller Software Telecommunications Installation
Web Portal Telephone Companies
Website Hosting Video Conferencing Services
Website Construction and Design Voice over Internet Protocol Services (VOIP)
Wholesale software distribution Wireless Communication
Other (describe) Other (describe)
Installation % Miscellaneous Professional Services – (describe) %
Cabling - Inside
Cabling - Outside
Computers & Peripherals
Software
Telecommunications Equipment
Other (describe)
   
   
V. CLIENT/CUSTOMER INFORMATION – to be completed by all applicants
   
   
1. Provide the following information regarding your five (5) largest clients (determined as a percentage of the total gross revenue for the past fiscal year):
   
Client Size of Contract Length of Contract Description of Services
   
2. What is the percentage of sales to repeat customers? %
3. What is your average contract size? $
4. What is the average length of your contracts?
5. Rate the technical level of sophistication of your average customer?
 Novice  Average  Sophisticated
6.Indicate the percentage of products and services you provide to the following Customer Segments:
 Yes  No  
8. Indicate the percentage of revenue derived from the following Business Sectors:
Customer Segment % of Services/Products
Commercial Client
Individual Consumers
United States Federal Government
United States State And Local Governments
Foreign Governments
   
Business Sector % of Receipts Business Sector % of Receipts
Aerospace & Defense Healthcare
Automobiles & Components Information Technology
Chemical Manufacturing
Construction & Engineering Media
Consumer Services Oil, Gas & Utilities
Electrical Equipment Retail
Energy Equipment& Services Telecommunication
Financial Services Transportation
   
9. Do you hold non-public information on behalf of your client(s)?  Yes  No
If yes, please complete Section X Information Security.
   
VI. CONTRACTUAL PROCEDURES – to be completed by all applicants
   
   
1. Do you require the use of a written contract or agreement for all engagements?  Yes  No
What percent of contracts are in writing? %
2. Do you maintain and enforce a contractual review process?  Yes  No
3. Does this process include review by Legal Counsel?  Yes  Yes
4. Do you have a standard written contract that you use on most engagements?  Yes  Yes
5. Indicate the percentage of contracts where your standard contract, the customer's contract or a combination of both is used: Standard %
  Customer %
  Combination %
6. What is the acceptable downtime if your product or service should fail  None  Less than 1 day
   Less than 2 days  Over 2 days
7. What contractual provisions do you strive to impose on most contracts? (select all that apply):
   
 Disclaimer of Warranties  Hold Harmless to your Benefit
 Dispute Resolution  Limitation of Liability
 Exclusions for Consequential Damages  Performance Milestone
 Exclusive Remedies  Statement of Work
 Force Majeure  Venue or Governing Law
8. Do you have a formal customer acceptance process in place?  Yes  No
9. Are performance milestones accepted with signoffs by both parties?  Yes  No
10. Are interim changes in contracts documented and signed off by both parties?  Yes  No
11. Does anyone other than a principal have the authority to amend the standard contract?  Yes  No
If yes, who?
VII. QUALITY CONTROL PROCEDURES – to be completed by all applicants
   
   
1. Do you employ a Risk Manager?  Yes  No
If no, please indicate who is responsible for handling insurance related matters:
2. Do you have policies and procedures in place to respond to customer complaints?  Yes  No
3. Do you utilize an escalation procedure to respond to customer complaints?  Yes  No
4. In your opinion, what is the worst case scenario if your product or service should fail?
     
5. Indicate which of the quality control procedures are in place: (select all that apply)
     
 Alpha Testing  Customer Service via E-Mail
 Beta Testing  Formalized Training for New Hires
 Business Continuity Plan  Prototype Development
 Customer Screening Process  Vendor Certification Process
 Customer Service via a Toll-Free Number  Written Quality Control Guidelines
 Customer Service via a Web Portal  Other:
6. Do you have a disaster recovery/business continuity plan?  Yes  No
How often to do you test it?  
7. Do you back-up network data and configure files daily?  Yes  No
If not daily, then how often are data and files backed-up?
Do you store back-up files in a secure location? Where?
 Onsite
 Offsite
VIII. SUB-CONTRACTED WORK, USE OF SUPPLIERS AND OUTSOURCED MANUFACTURING –
to be completed by all applicants
   
   
1. Do you sub-contract any professional services or manufacturing to fulfill commitments to clients?  Yes  No
2. If yes, what percentage do you sub-contract? %
3. Do you utilize a standard sub-contractor contractor?  Yes  No
4. Do you require evidence of General Liability from subcontractors?  Yes  No
5. Do you require evidence of Errors & Omissions insurance from subcontractors?  Yes  No
   
IX. MEDIA -Complete only if applying for Media Liability or copyright of software code
   
Business Activities or Website contents % of Receipts   % of Receipts
Advertising/Marketing for others Music or sound clips
Executable programs or shareware Pornographic or sexually explicit material
File sharing Sweepstakes or coupons
Interactive gaming Video Producers
Movie/Commercial Production Other (describe)
Website Content Provider % Open Source %
Content created by applicant Open Source Code originated by applicant
Content supplied by client Open Source Code created by others and used by applicant
Domain Name Registration  
   
1. If you distribute computer systems with software included, are the appropriate license agreements supplied with each system?  N/A  Yes  No
2.Do you follow all contractual requirements when distributing hardware or software manufactured by others?  N/A  Yes  No
3. Is the ownership of intellectual property created by you, or on your behalf, clearly stated in all customer contracts and followed by you?  N/A  Yes  No
4. If you sell used equipment, are new license agreements purchased?  N/A  Yes  No
5. Do you have a procedure for reviewing all content that is disseminated via your website?  Yes  No
6. Does your website, or any website managed by you, include chat rooms, bulletin boards, or blogs?
If yes, do you review and edit prior to posting?  Yes  No
Do you have a formal procedure for removing controversial or infringing material?  Yes  No
 Yes  No
7. Have you received notification that any of your material or services infringe on the intellectual property rights of others?  Yes  No
8. Risk Management Procedures for all Media Activities
a. Do you employ an in-house counsel who specializes in intellectual property rights?  Yes  No
b. Do you have written intellectual property clearance procedures?  Yes  No
c. Do you acquire all necessary rights, licenses or consent to use of content?  Yes  No
d. Do you require employees and contractors to sign a statement that they will not use previous employers' or clients' intellectual property?  Yes  No
e. Do you have agreements in place with contractors, working on your
behalf, granting you ownership of all intellectual property developed for you?
 Yes  No
X. INFORMATION SECURITY- Complete only if applying for Network Security & Privacy Injury Liability
Coverage or if you are responsible for non-public information on behalf others
   
   
(Complete only if applying for Network Security & Privacy Injury Liability Coverage or if you are responsible for non public information on behalf others.)
   
1. Have you dedicated at least one staff member to manage, on a full-time basis, information security such as a Chief Information Security Officer or equivalent, or is this function outsourced to a qualified firm?  Yes  No
2. Do you have a written security policy that must be followed by all employees, contractors, or any other person with access to your network?  Yes  No
3. Have you established employee awareness and/or security training programs?  Yes  No
4. Do you disclose a privacy policy and always honor it?  Yes  No
5.Has your privacy policy been reviewed by:
   Qualified Attorney
   3rd Party (TRUSTe, eTrust)
   Neither
6. Please indicate which type of third party sensitive information resides your network:
(Select all that apply)
   Credit card data for the duration of a transaction
   Credit card data stored for future use (all but last 4 digits masked)
   Credit card data stored for future use (un-masked card numbers or including track 2 data)
   Private health information
   Sensitive or proprietary company information (including trade secrets)
   Other personally identifiable financial information (Describe)
7. a. Do you use wireless networks?  Yes  No
  b. If yes, do you use security at least as strong as WPA authentication and encryption, requiring two factor authentication (e.g. Some combination of VPN or Access Token, and password/account logon) before allowing wire connections to the network?  Yes  No
  c. Have you established an internal security breach incident response team?  Yes  No
  d. Have you established a formal, written security breach response plan?  Yes  No
  e. Does the plan contain a process for assessing whether a breach notice is legally mandated?  Yes  No
  f. Does the plan contain a process regarding the proper means to communicate the breach?  Yes  No
TECHNICAL SECURITY      
1. a. Do you implement virus controls on all of your systems?  Yes  Yes
  b. Please check all items that accurately describe this program:
   
 Anti-virus/malicious code software is deployed on all computing devices within your network
 Automatic updates occur, at least, daily
 Anti-virus scans are performed on all e-mail attachments, files and downloads before opening
 Rejected files are quarantined
 Unneeded services and ports are disabled
 Virus/information security threat notifications are automatically received from CERT or similar
2. a. Do you have a firewall in place?  Yes  No
  b. Please check all items that accurately describe the firewall:
   
 A formal process has been established for approving and testing all external network connections
 A firewall has been established at each Internet connection
 A firewall has been established between any DMZ and Intranet connection
3. Do you install and configure anti-spyware software to provide maximum protection of personally identifiable/sensitive information on all servers, desktops PCs, and laptops?  Yes  No
4. Do you check for security software updates and patches at least weekly and implement them within 30 days?  Yes  No
5. Do you have a way to detect unauthorized access or attempts to access sensitive information (e.g. intrusion detection systems, review of access logs)?  Yes  No
ADMINISTRATIVE SECURITY      
1. Do you control access to information that resides on data storage devices such as servers, desktops, PCs, laptops, and PDAs?  Yes  No
2. Do you control access to information that can be displayed, printed,
and/or downloaded to external storage devices?
 Yes  No
3. Are you able to identity whose non-public information is being held and how to contact individuals if their information is breached?  Yes  No
4. Do you monitor user accounts to identify and eliminate inactive users?  Yes  No
5. Do you use reasonable encryption methods when transmitting, receiving
or storing personally identifiable/sensitive information?
 Yes  No
6. Do you replace factory default settings to ensure information security systems are securely configured?  Yes  No
7. Do you retain personally identifiable information only for as long as needed?  Yes  No
8. Do you discard personally identifiable information when no longer needed by irreversibly erasing or destroying the data using a technique that leaves no residual data?  Yes  No
9. Whenever you entrust sensitive information to third parties (e.g. hosting providers, back-up and data recovery, document storage, shredding and data destruction) do you contractually require all such third parties to protect this information with the same obligation that you owe to others and to comply with any applicable privacy law?  Yes  No
10. Does your hiring process include conducting background checks on employees and independent contractors?  Yes  No
11. Are procedures in place to prevent the unmonitored use of development tools or high level administrative access privileges from being used to create security vulnerabilities on your networks?  Yes  No
PHYSICAL SECURITY      
1. Have you established physical security controls to control access to sensitive data?  Yes  No
2. Do you limit server, server room and data center access only to authorized personnel?  Yes  No
3. a. Do your removable devices such as laptops, PDAs, thumb drives,
tapes or diskettes (removable media) contain non-public personal or commercial information?

If "yes", attach a detailed description of the type of information contained on these devices.

 Yes  No  N/A
  b. Do you encrypt personally identifiable information stored on removable media and ensure that the encryption/decryption keys are not also stored on that device unless they are protected by 2 factor authentication (password protection alone is not sufficient).
 Yes
4. Do you have an established procedure for employee departures that includes an inventoried recovery of all information assets, user accounts, and systems previously assigned to each individual during their period of employment?  Yes  No
XI. HISTORICAL BUSINESS INFORMATION – to be completed by all applicants
   
   
1. Do you have any account receivables for professional or technology
service contracts that are more than ninety (90) days past due?

If "yes" attach details

 Yes  No
2. Within the past five (5) years, have you sued any customers for non-payment of any contract or licensing fee?

If "yes" attach details

 Yes  No
3. Within the past five (5) years, have any customers withheld payment or requested a refund of fees because your products/services (If "yes" attach details):
  a. Did not meet customer's performance expectations?  Yes  No
  b. Did not meet customer's performance expectations?  Yes  No
   
XII. HISTORICAL CLAIMS & INVESTIGATORY INFORMATION – to be completed by all applicants
   
   
1. Does your Chief Executive officer, Chairperson, Chief Financial Officer, President, or Risk Manager have knowledge, information of any circumstance, or any allegation of contentions of any incident that could give rise to a claim that would be covered by this policy?

If "yes" attach a detailed summary including the name of the claimant, the date the claim occurred, the date it was reported, the demand amount and any other pertinent details.

 Yes  No
2. Have you received any complaints, claims, or been subject to litigation involving matters of privacy injury, identity theft, denial of service attacks, computer virus infections, theft of information, damage to third party networks or your customers ability to rely on your network?

If "yes" attach details

 Yes  No
3. Within the last five (5) years, have you been the subject of an investigation or action by any regulatory or administrative agency arising out of your business practices?

If "yes" attach details

 Yes  No
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FRAUD NOTICE – WHERE APPLICABLE UNDER THE LAW OF YOUR STATE

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES (For DC residents only: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim were provided by the applicant.) (For FL residents only: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.) (For LA residents only: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.) (For ME residents only: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.) (For NY residents only: and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.) (For Oklahoma residents only: any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony." The absence of such a statement shall not constitute a defense in any prosecution. (For PA residents only: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.) (For TN and WA residents only: Penalties include imprisonment, fines and denial of insurance benefits.) (For VT residents only: any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false or incomplete information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which may be a crime and may be subject to civil fines and criminal penalties.

The undersigned officer certifies that he or she is an authorized representative of the applicant identified in Part I above and certifies that reasonable inquiry has been made to obtain answers to these questions. He/she certifies that the answers are, to the best of his/her knowledge and belief, true, correct and complete. Signing this application does not constitute a binder or obligate CNA to provide this insurance, but it is agreed that this application is the basis upon which CNA may issue a policy.

By:    
  Signature of Authorized Representative   Printed Name of Authorized Representative
Title:   Date:  

Agent: Chris Hofmann, CIC
Abco Insurance Agency
2023 Route 70 West, Cherry Hill, NJ 08002
Phone (856)488-5333 / Fax (856)488-1125
Email: chofmann@graniteinsuranceagency.com

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