General & ProFeSSional ServiCeS liaBiliTY neW BUSineSS ...

INTELLECT TECHNOLOGY GENERAL & PROFESSIONAL SERVICES LIABILITY NEW BUSINESS APPLICATION

Sovereign General

Along with this application, we ask that you attach copies of the following information: 1. Loss runs for the last five years 2. Your most recent annual report or audited financial statements 3. Copy of Standard Contracts and/or Agreements used with clients 4. Latest edition of your Internet and Network Security Policy (if applying for Network Security & Privacy Breach Liability) 5. Latest edition of your Privacy Policy (if applying for Network Security & Privacy Breach Liability)

COVERAGE REQUESTED

Current Policy Term: Requested Effective Date: Request for the following Coverages:

q General Liability q Professional Services Liability q Network Security & Privacy Breach Liability q E-Media Liability

GENERAL INFORMATION

Name of Insured (Include names of all subsidiary companies to be insured):

Principal Address (street, city, province and postal code):

Branch Address (street, city, province and postal code):

Website Address:

Date firm established:

Named Insured is:

q Corporation

q Partnership

q Other (Please describe):

q Joint Venture

q Individual

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NEW BUSINESS APPLICATION

Sovereign General

GENERAL INFORMATION (cont'd)

Revenue

CanadaU.S.ForeignTotal

Last year:$$$$

Projected current year: $$$$

Projected next year:

$$$$

1. Please list the countries that account for your foreign revenues:

Employees CanadaU.S.ForeignProfessionalSales

RepresentativesClericalOther

Acquisitions & Divestures

1. Have any operations or portions therefore, been sold during the past three (3) years?

q Yes

If yes, were the liabilities retained?q Yes

2. Have there been any acquisitions of, or mergers with any companies in the past three (3) years?

q Yes

If yes, please describe:

q No q No q No

Products & Services 1. Provide a full description of operations (attach additional sheet(s) if required):

2. Describe the end user of the products/services:

3. Please select all of the following products and services currently generating revenue for the organization:

Application Services Provider% E-Commerce%

Data Processing Services

%

Custom Software Development

%

Computer Facilities Management

% Network Security Consulting

%

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NEW BUSINESS APPLICATION

Sovereign General

GENERAL INFORMATION (cont'd)

Computer Integrated System Design

%

Training and Education

%

Computer Maintenance and Repair

%

Web development

%

Computer Rental and Leasing

%

Business Software as a Service

%

Information Retrieval Services

% VoIP systems/Telephone systems/

%

(Data Base Management)install support

Internet Service Provider% Manufacturing%

Network Integrator% Wholesale%

Prepackaged Software% Distribution%

Web hosting% Retail%

Technology Consultants% Assembly%

Software Licensing% Other%

Technical Research%

4. Please indicate the principal market(s) for your products or services and revenue split for each:

Aerospace or Avionics

%Enterprise Resource Planning

%

Customer Relationship Management

%

Supply Chain Management

%

Enterprise Application Integration

%

Fire, Security or Emergency Applications %

Electronic Security Advice/Products%Privacy Applications%

Process Control (monitoring or safety critical) %Oil & & Gas/Power/Nuclear Energy

%

Pollution or Environnemental

%

Municipal or Provincial Government

%

Federal Government%Anti Terrorism Applications%

Military / Defence

%

Banking of Financial Transactions

%

Content or Knowledge Management

%

Smart Card / Smart Chip

%

Payroll or Accounting%Human Resources%

Entertainment or Gaming

%

eBusiness Consulting Services

%

5. How many customers represent more than 10% of the total revenue?

6. Please list the top 5 customers, annual revenue generated, and a brief description of the products or services provided:

CustomerAnnual Revenue

Contract (Years/Months) Product/Service

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NEW BUSINESS APPLICATION

Sovereign General

GENERAL INFORMATION (cont'd)

7. What would be the largest financial loss, and nature of loss, suffered by any customer should the product and/or service fail?

8. Have any products or services been discontinued in the past three years?

q Yes q No

9. Describe any future products and/or services that are under development and expected to go to marketing within the next few years:

Customer Contracts & Agreements 1. What is the dollar value of the largest contract or agreement? 2. What is the length of the largest contract, agreement or purchase order (year/months)? 3. What is the dollar value of a typical contract or agreement? 4. What is the length of a typical contract or agreement (year/month)? 5. What is the average length of an installation or integration (month/years)? 6. Do all of the contracts or agreements limit liability to the cost of the products or services? If no, please explain:

$ $ q Yes q No

7. a) Is liability ever accepted for consequential damages? If yes, please explain:

q Yes q No

b) Is liability ever accepted for liquidated damages? If yes, please explain:

q Yes q No

Individual Contracted Workers (Do not include work generated by subcontracting firms): 1. Are any individuals hired to perform work on a contract basis? 2. Do individuals work under your direction? 3. Are background checks performed on these individuals? 4. Does your company intend to assume liability for their work performed on your behalf? If no, is evidence of professional liability insurance for those individuals obtained? If yes, please advise for which products and/or services:

q Yes q Yes q Yes q Yes q Yes

q No q No q No q No q No

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NEW BUSINESS APPLICATION

Sovereign General

GENERAL INFORMATION (cont'd)

Subcontracted Work 1. Are subcontractors hired to develop, manufacture, assemble, implement or support the product or service? q Yes If yes, please advise for which products and/or services:

q No

2. What percentage of work is generated by subcontractors?

%

3. Are Certificates of Insurance required from all subcontractors?

q Yes

If yes, for what limit of liability:

General Liability (including Products):$

Professional Liability:$

4. Does your company intend to assume liability for their work performed on your behalf?

q Yes

If no, is evidence of professional liability insurance for those individuals obtained?

q Yes

If yes, what limit of liability is required?

$

q No

q No q No

Quality Control 1. Does the quality control policy include the following?

q Alpha testing q Beta testing q Customer acceptance procedures q Documented and practiced quality control program q Policy for documenting & responding to customer inquiries', complaints, requests q Product recall plan

COMMERCIAL GENERAL LIABILITY APPLICATION

If coverage is required for Intellect Professional Services Liability only, please refer to the Intellect Professional Services Liability Application.

Limit of Insurance (each claim /aggregate claim): q $1,000,000 q $2,000,000 q $5,000,000 q Other $

Deductible (each claim):

q $2,500

q $5,000

q $10,000

q $25,000

q $50,000

q $100,000

1. Can the end user alter the product manufactured by the insured?

2. Are there any safety devices or labels that would prevent alteration?

If yes, provide detail:

q Other $ q Yes q No q Yes q No

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