IT LIABILITY  INSURANCE  This product has been tailored to the specific needs of theTechnology Industry by offering a comprehensive combined Professional Indemnity and Public and Products Liability solution with separate limits and deductibles. COMPLETE THE INFORMATION BELOW AND WE WILL PROVIDE YOU WITH A REAL TIME QUOTE The Provision of this REAL TIME  QUOTE  does not signify an acceptance of cover, nor does it constitute a contract of insurance. If you have any questions please contact  Abe Tavares (02) 1300 85 27 39                                        Your Email Address     Your Name   Telephone No:                 Company Legal Name          Country or State of Registration    ABN/ACN No:   Business Start Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 January February March April May June July August September October November December   1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012   Address of Principal Location Street                              Suburb                     State                                Select >> NSW QLD VIC TAS SA WA NT    Postcode                           Number of Staff   Select >> 1-5 6-10 11-15 16-100 Gross Turnover $     Description of Business   Are any of your products/services intended for use in any of the following: Medical/Surgical Applications Aerospace/Radar/Navigation Systems Oil, GasPower / Nuclear Energy Applications Manufacturing Process Control Systems Security Systems Yes No   Please provide an approximate breakdown of Activities and a % of Work Hardware Sales Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Hardware Sales (Own Developed) Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Third Party software Sales Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Software Sales (Own Developed) Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% ISP / Web / Internet Services Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Telecommunication Services Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Integration Services Select >> 0 Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Maintenance Services Select >> 0 Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Data Processing / Warehousing Services Select >> 0 Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Bureau Services Select >> 0 Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% General Consultancy/ Programming Select >> 0 Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Education and Training Select >> 0 5% 10% 15% 20% 25% 30% 33.3% 35% 40% 50% 60% 65% 66.6% 70% 75% 80% 85% 90% 95% 100% Other Select >> 0 5% 10% 15% Do you envisage any substantial changes in your activities or are there any major new operations contemplated during the next 12 months? Yes No   Please provide the approx. percentage of your Turnover applicable to each State, Territory and overseas or outside of Australia NSW VIC QLD SA ACT WA TAS NT Overseas   0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% %   0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% %   0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% %   0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% % 0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% %   0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% %   0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% %   0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% %   0 0 5% 10% 15% 20% 25% 30% 35% 40% 50% 60% 65% 70% 75% 80% 85% 90% 95% 100% % Select the Insurance Indemnity limits you require       Profesional Indemnity Limit Required  Select > $1,000,000 $2,000,000 $5,000,000 $10,000,000   Public and Products Liability Limited Required  Select > $5,000,000 $10,000,000   OPTIONAL EXTENSIONS Is Cover required for USA/Canada Cover   Yes No Consultants, Subcontractors and Agents (see note below)   Yes No You are only required to answer YES if you utilize contractors, consultants or agents in your business and would like to insure them for the work that they perform for your business. If all work for your business is performed by yourself or employees then tick NO. You should always ensure that any contractors (etc) that you utilize carry their own insurance. After Enquiry Have any claims been made against you for Information Technology Insurance? Yes No      Is the Proposer or any of the Principals,Partners,Directors or Employees awhare of any circumsatnces or incident which may give rise to a Claim against the Company or any present or former Principals, Partners, Directors or Employees? YesNo      Has any client disputed payment for products or services rendered? YesNo      Has any contract or project experienced cost overruns, delays, system failures or funtional problems?  YesNo      Has the Company or any Principal, Partner or Director ever been refused or cancelled insurance, or had a renewal application denied or had special terms imposed?  Yes No      If you have answered YES to any of the above questions or undertake business outside Australia, Please provide details. If you have been in business less than 12 months  please provide details of experience skills etc Please advise us who referred you to this web site Please Note it will take 30 seconds or so to generate the quote and email it to you. You will be then redirected to a confirmation page           © 2008 APEX Insurance Brokers                                                            Terms of use                                         Developed by Interactive Concepts           29/10/2007
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