On-line Information Technology Liability Insurance



Thank you for considering our on-line professional indemnity insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right professional indemnity for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.


1. Please state amount of preferred Total Sum Insured and Excess:
$ Total Sum Insured $ Excess
a) Policy One - Professional Indemnity
b) Policy Two - Public/Products Liability
Note: Usually subject to the following minimum Sums Insured and Excess:

a) Policy One - Professional Indemnity.
Total Sum Insured - $1,000,000 Excess - $1,000

b) Policy Two - Public/Products Liability.
Total Sum Insured - $5,000,000 Excess - $500, property damage claims only
2a. Do you currently hold professional indemnity and/or liability insurance?
Yes No
2b. If you are not currently insured, have you ever held professional indemnity and/or liability insurance?
Yes No
If the answer to either of the above is "Yes",please complete the table below for the past 2 years you were insured.
Name of Insurer Period Insured Type of Cover $ Sum Insured $ Excess
3. Have you ever had a professional indemnity or liability insurer decline a proposal, impose special terms, decline to renew or cancel your insurance?
Yes No
If the answer is "Yes", Please provide details
4. Please enter the full nature of the activities to be covered and type of advice given
5. Particulars of all Principals and Directors
Years Practising
Name of Principal/Director Age Qualifications Current Business
Practices
Previous Business
Practices
Name of Previous
Business Practices
6. Resume/CV: If not contained on your website, please copy & paste or email a brief resume for each Principal and/or Director.
7. Total number of:
(a) Qualified staff-including Principals
(b) Other technical staff
(c) Non-technical staff (including typists, receptionists etc.)
Total of all staff
8. Have you amalgamated or merged with any other business?
Yes No
If yes, please provide details:
9. Is any Partner, Principal or Director connected or associated (financially or otherwise) with any other business?
Yes No
If yes, please provide details:
10. Are you a member of a professional association or society?
Yes No
If yes, please provide details:
11. Please provide the following information:
$ Australia/NZ $ Overseas
a) Gross professional fees earned for the past 12 months.
(include fees paid to consultants, sub-contractors and
agents appointed by you).
b) Estimated gross professional fees for the next 12 months.
(include in the estimate fees expected to be paid to
consultants, sub-contractors and agents appointed by you).
c) Gross turnover (including all revenue from sales, manufacture
or installation) for the last 12 months.
d) Estimated gross turnover (including all revenue from sales,
manufacture or installation) for the next 12 months.
12. State fully the nature of your business, including the primary purpose of software and systems provided, sold or
licensed. (Please copy & paste or email any brochures or other documentation which may assist in explaining your
business activities).
13. Please state the approximate percentage of your income disclosed in answer to Question 11(a) or 11(b) which is derived from the following fields of activity:
a) Software Developer
Asset/Inventory Management %
Business Systems %
Communication Systems %
E-Commerce %
Financial/Accounting %
Gaming %
Geographical/Spatial %
Graphics/CAD %
Manufacturing (Control) %
Media/Entertainment %
Medical Systems (Non-Life) %
Mining/Oil/Gas and Utilities %
Miscellaneous %
Modelling, Analysis %
Retail Systems (POS) %
Systems Software %
Transport Systems %
Utility Software %
Websites %
b) Data Processing/Warehousing Services %
c) Education and Training %
d) Facilities Management or Outsourcing %
e) General Consulting %
f) Hardware Sales (Own Developed) %
g) ISP/Web/Internet Services %
h) IT Recruitment and Placement Services %
i) Maintenance and Repair %
j) Reseller of Third Party Software and Hardware %
k) Systems Integration %
l) Telecommunication Services %
m) Other (please describe) %
n) Total %
14. Do you import any products associated with the fields of activity listed in Question 13?
Yes No
If the answer is "Yes", please provide details:
15. Have you discontinued developing, manufacturing, producing or handling any software /hardware or information technology system?
Yes No
If the answer is "Yes", please provide details:
16. Do you provide services or products intended for use in the following areas?
Yes No
If the answer is "Yes", please advise the percentage of your income disclosed in answer to Question 11(a) or 11(b)
which is derived from such services or products.
Aerospace, aircraft and radar navigation systems %
Credit Card processing or Billing systems %
Electricity Generation or Distribution %
Financial or Banking services %
Medical/Surgical applications %
Military systems %
Nuclear Installations %
Oil, Pipelines and Refineries %
Robotic control or manufacturing mining process controls including PLC and SCADA programming %
Web portal programming %
ERP systems %
Fire/Security/Emergency services %
Mobile phone/Wireless Access programming %
Note: We may require further information about your involvement in these areas and coverage may not be available
for these risks.
17. Do you act as an agent for any company(ies)?
Yes No
If the answer is "Yes", please provide details
Company Software/Hardware services provided
in accordance with the agreement
$ Income earned
from Agency
18. Please provide a brief description of the two (2) largest projects undertaken by you in the past five (5) years.
Project/Contract description Your role $ Fees earned $ Contract value
19. Do you wish to cover your consultants, sub-contractors or agents, in respect of work performed on your behalf?
Yes No
If Yes, a) Please give details of the nature of work performed and the names of all consultants, sub
contractors and agents to be covered.
b) Please state the gross professional fees paid to consultants,
sub-contractors and agents to be covered, during the past 12 months.
20. Have you ever undertaken, or are you likely to undertake, work outside of Australia and New Zealand?, If the answer is "Yes", please give details below
Yes No
Country Date of
completion
$ Annual income Type of work
21. Please state the approximate percentage of Your activities (based on income) applicable to each State, Territory and Overseas.
NSW  VIC  QLD  SA  WA  TAS  NT  ACT  O/S
%  %  %  %  %  %  %  %  %
Please answer the following questions after enquiry within your organisation.
22. Has any Partner, Principal, Director or staff member ever been subject to disciplinary proceedings for professional misconduct?
Yes No
If "Yes", please give the details below:
23a. During the past 10 years, has any claim been made or has negligence or breach of professional duty been alleged, against the business, or any of the present or former principals, partners or directors, or have any circumstances which may give rise to a claim been notified to insurers?
Yes No
If the answer is "Yes", please give details below
Year notified Insured with Claimant Nature of problem $ Amount paid /
outstanding
23b. Have any claims been made against you for information & communication technology liability including professional indemnity and product liability?
Yes No
If the answer is "Yes", please give details below
Year notified Insured with Claimant Nature of problem $ Amount paid /
outstanding
24. Are any of the partners, principals or directors aware of any claim or circumstances which may give rise to a claim aganist the business or any prior business, partners or directors or any of the present or former principals?
Yes No
If the answer is "Yes", please give details below
Name of Practice and Principal Claimant Nature of problem $ Estimate
25. Has any contract or project experienced cost overruns, delays in implementation, failure of system(s) and/or product(s) to meet full functionality?
Yes No
If the answer is "Yes", please give details below
Client/Contract Name Brief Description of Problem
26. Has any client refused payment or requested a refund of monies paid?
Yes No
If the answer is "Yes", please give details below
Client Amount of Refund or Non Payment
$
$
$
27. Do you have International Standards Organisation (ISO) certification?
Yes No
28. Do you have a formal customer acceptance procedure?
Yes No
29. Do you require a final acceptance letter or other sign-off agreement from the customer?
Yes No
30. Do you maintain written logs for customer reports of problems or down-time?
Yes No
31. Do you retain all records in terms of products and services supplied for a period of at least seven (7) years?
Yes No
32. Are all employees required to sign statements that they will not use any previous employers' trade secrets or other information?
Yes No
If NO, What controls do you have to prevent potential infringement of trade secrets or property information of third parties?


Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured: Date of Commencement
Are you registered for GST purposes?
Yes No
ABN:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address:
Country: