CFC Tech Insurance Application

1 Company

2 Activities

3 Contracts

4 Cyber Security

5 IP Rights

6 Claims

7 Additional

8 Property (App. 1)

Company Details

1.1 Company Name *

Primary Address *

Website Address

1.2 Date Business Established

1.3 Number of Employees

1.5 Financial Year End

1.6 Gross Revenue

All figures in USD ($)

	Last Complete FY	Current FY Estimate	Next FY Estimate
Domestic Revenue
Other Territory Revenue
Total Gross Revenue
Profit / (Loss)

1.7 Primary Contact for this Insurance Policy

Activities

2.1 Describe the products and services supplied by your business

2.2 Revenue breakdown by product/service type

e.g. Software customisation, Hardware design, Hosting, IT security consulting, SaaS, etc.

Total: 0%

2.3 Sector breakdown (must total 100%)

Consumer%

Manufacturing%

Entertainment%

Retail%

Financial Services%

Telecommunications%

Government%

Transportation%

Healthcare%

Other%

Total: 0%

If "Other" sector, please describe

Contract & Risk Management Information

3.1 Three Largest Projects (Past 3 Years)

Client NameNature of WorkAnnual Contract IncomeDuration

3.2 Approximate number of customers

3.3 Do you always carry out work under a written contract signed by every client?

Yes No

3.4 How do you limit your liability for consequential loss or financial damages under a written contract?

3.5 Describe your legal review process before entering into new contracts or agreements

3.6 Describe the impact on your clients if your products or services failed

3.7 Do you employ subcontractors?

Yes No

If Yes — Subcontractor Details

a) Approximate % of revenue paid to subcontractors (current FY)

b) Do you sign reciprocal hold harmless agreements?

Yes No

c) Do you ensure subcontractors have their own E&O and CGL insurance?

Yes No

If yes to c) — Required limit of liability ($)

Intellectual Property Rights Risk Management

5.1a Procedures for preventing infringement of third-party IP rights

5.1b Procedures for obtaining licenses and monitoring third-party IP rights

5.2a Have you ever sent or received a cease and desist letter relating to IP rights?

Yes No

5.2b Have you ever sent or received a notification of an actual or potential claim letter?

Yes No

Please provide full details of the above

5.3 Procedures for managing IP rights issues, including qualifications of the responsible individual

Claims Experience

7.1a Are you aware of any incident which may result in a claim under any of the insurance you are applying for?

Yes No

7.1b Has any legal action been made against any of the companies to be insured within the last 5 years?

Yes No

Please describe the incident(s) in full

Include monetary amounts, dates, and current status of any claims

Additional Information

Please also provide the following documents separately: (1) Directors/principals resumes if trading <3 years; (2) Organisation chart if subsidiaries are to be insured; (3) Standard form of contract, EULA or terms of use.

Subsidiary / Group Structure

If any subsidiaries are to be insured, complete below

NameDate of AcquisitionCountry of Domicile% Ownership

Any other relevant information

Declaration — Contact Name

Date (MM/DD/YYYY)

Important notice: By submitting this form you agree that the information provided is both accurate and complete. CFC Underwriting will use this information solely for the purposes of providing insurance services.

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