Business Insurance Form

General Liability
Are you designing software that involves any of the following:
Umbrella Liability
Workers Compensation
Applicant’s current professional liability:
Please provide the following documentation:
  • Software License Agreement
  • Sales Agreement
  • Distribution Agreement with Software and/or Hardware Manufacturer
  • Consulting Agreement
This application does not bind the company or applicant, nor does it obligate the company to insure applicant services or issue a policy. If a policy is issued, the company may cancel such policy upon discovery of fraudulent statements, omission or concealment of the facts material to the acceptance by the company.

The applicant also warrants that such statements and responses are true, contain no misrepresentation and that if the information that is supplied on this application or attachments changes between the date of this application and the inception date of the policy, the applicant will immediately notify the company of such changes.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance concerning any material fact thereto, commits a fraudulent act, which is a crime. In New York, any person shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each violation.

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