Professional Indemnity
Proposal Form
For the Technology Industry
This is a proposal for a claims made policy

The policy will only respond to claims and/or circumstances, which are first made against the Insured and notified to the
Insurer during the policy period. The policy will not provide cover for:-
* Events that occurred prior in the retroactive date of the policy (if specified)
* Claims made after the expiry of the policy period even though the Wrongful Act giving rise to the claim may have
occurred during the policy period.
* Claims notified or arising out of facts or circumstances notified under any any previous or noted on the current
proposal form or any previous proposal form.
* Claims made, threatened or intimated prior to the commencement of the policy period.
* Facts or circumstances in your knowledge prior to the policy period, which you knew had the potential to give rise to
a claim under the policy.
DISCLOSURE
You must disclose to the Insurer all information which is material to it in deciding whether to issue insurance cover
to you, including any facts or conduct which might lend to a claim being made against you. Failing to do so could affect
your right to indemnity.
If you do not understand any part of this document, please contact your Broker BEFORE YOU SIGN IT. You will be
bound by the answers, which are given, and by the information provided by you in this proposal form. It is in you
interest to make sure that all information is correct and properly understood.
When in doubt disclose
ATTACHMENTS
Before you return this form, have you included the following (please indicate by Ticking the boxes):
Standard client contract agreement
Company brochure/additional information
Claims information (if relevant)
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Please state the name & address of the principal Company for whom this Insurance is required. Cover is also provided
for the subsidiaries of the Principal Company, but only if you include the data from all of these Subsidiaries in your
answers to all of the questions in this form:
Insured Company: Contact Name:
Telephone: Fax:
E-Mail Address: Website:
1.2 Please state when your company was established?
1.3 i ) How many directors are there in the Company
ii ) Please show the details of all Partners/Directors: Details attached as per separate annexure
Name Years in position Years experience Qualifications
iii) Please state the number of employees as on July 31 2005
Marketing/Sales/Business Development __________21_____other_________24____
I.T./technical__________207_______________________
1.4 Please state your fees received in respect of the following years
Currency___INR____________
Date of financial year end
31______/__Mar______
( dd / mm)
Last complete financial
Year
Estimate for current
Financial year
Estimate for next financial
year
(a) Domestic turnover:
(b) USA turnover
(c ) Other territory
turnover
TOTAL turnover:
OPERATING
PROFIT/(LOSS)
-
2.1 Please provide a full description of your activities
(If you have a brochure, or company literature, please attach to this form)
a) Hardware:
i. Sales of own brand
ii. Distribution of other brands
iii. Installation
iv. Maintenance
b) Software product sales
i. Sales of own brand shrink wrapped/off the shelf software
ii. Distribution of other brand shrink wrapped/off the shelf software
iii. Customisable software
c) Software services
i. Installation, including configuration (No coding involved)
ii. Customisation (including coding changes)
iii. Maintenance
iv. Systems integration
c) Services
i. Consultancy
ii. Contract staff
iii. Facilities Management
iv. Project Management
v. Training
vi. Data processing
vii. Data communication services(including providing internet access)
e) Other Please give full details below
2.2 Are you involved in anyway in medical, financial or aviation software?
2.3 Is the failure of any of your products or services liable to result in any of the following outcomes:
a) Loss of life or injury to a person?
b) Destruction or damage to physical property
c) Immediate and large financial loss?
d) Significant cumulative financial loss?
e) Insignificant financial loss (more of a nuisance)
If you have answered YES to any of the above then please explain below, and also describe the
Worst thing that could happen to your customers' operations if your product(s)/service were to fail:
3.1 Please give details of the five largest contracts you have carried out in the past three years.
Names of client Business
of client
Nature of Work Total Value Income to
you (in INR)
Start
Date
Completion
date
Homestore Inc
PUMA
Ebbondacs
StorePerform
GE India Technology
Centre Pvt Ltd
3.2 How many customers do you have?___
3.3. Do you carry out work only under a standard contract signed by every client?
Please supply a copy of your standard form of contract, or typical examples of contracts used
3.4 Do you ever negotiate contracts with your customers in which you accept liability for Consequential loss or
financial damages, greater than the value of the contract?
3.5 What approximate percentage of your turnover, in your current financial year, will be paid
To sub-contractors? _____
3.6 Do you ensure that sub-contractors have their own professional indemnity insurance
4.1 Please provide details of your current professional indemnity insurance, if applicable.
Insurance Limit Excess Premium Insurer
Expiring terms
Requested terms
4.2 Regarding the risks to which this proposal relates (please see the product information section if you are not sure)
after enquiry:-
a) have any claims been made against any of the Companies to be insured, or partners or directors thereof, or
b) are you aware of any circumstances which may give rise to a claim against any of the Companies to be
insured or any partners or directors thereof, or
c) have any of the Companies to be insured or any partners or directors thereof suffered any losses, or
d) have any partners or directors of the Companies to be insured been found guilty of any criminal,
dishonest or fraudulent activity or been investigated by any regulatory body?
e) has there ever been an unforeseen outage on your computer system(s) for more than 3 (three)
hours?
If the answer to the above is 'YES', then please attach full details including an explanation of the background of
events, the maximum amount involved/claimed, the status of the claim(s) or circumstance(s) and any reserve(s) or
payment(s) made by you and/or by Insurers, and the dates of all developments and payments.
Declaration
• I/We declare that after proper enquiry the statements and particulars
Given above are true and that I/We have not mis-stated or suppressed any material fact.
* I/We agree that this Proposal Form, together with any other material
information supplied by me/us shall form the basis of any contract of
insurance effected thereon.
• I/We undertake to inform Underwriters of any material alteration to
These facts occurring before the completion of the contract.
Dated
Signed
Position held at Company