Information Technology

General Application Information

How did you hear about MOODY Tech Insurance?

Complete Business Name(Required)

Mailing Address/Street

City/State/Zip

Location Address/Street (if different from mailing)

City/State/Zip

Primary Contact Name(Required)

Contact Title

Phone Number(Required)

Fax Number

Email Address(Required)

Web Site Address

Type of Entity

(Sole Proprietor, Corporation, Partnership, LLC, etc)

Federal ID Number

Type of Business

(Describe typical services performed, customers served, products provided, etc.)

Sales Breakdown by % of revenue

Consulting and miscellaneous IT Services

% Custom Software Development

% Pre-Packaged Software Development

% Computer Programming

% System Maintenance and Repair

% Web Development

Web casting and conferencing

% Video teleconferencing

% Web Conferencing

% Voice teleconferencing

Network Service or Access

% ISP

% ASP

Computer Manufacturing and Assembly

% Systems

% Components

% Reselling-VAR/Systems Integration

Total for the breakdowns above (should add up to 100%)

Years In Business

If New Venture, prior experience

Do you work or sell product overseas

Yes

Current Insurance Information

Current Insurance Carrier (Name of Insurance Company)

How Long Insured

Date(s) Policy(s) Expire

Reason for Seeking New Carrier

Details of Losses/Claims over the Last 3 Years

Note: Complete below or fax us your loss runs at 301-417-0040

Location / Building Information

Construction

# of Stories

Year Built (approx.)

If over 30 years old, years of updating for

Wiring

Heating

Plumbing

Roof

Square Footage

Owner?

Yes

Tenant

Yes

Alarms?

Burglar

Fire

Local

Central Station

Sprinklers?

Yes

Coverage/Rating Basis Information

Property

Replacement Value of Contents ($)

Should include Leasehold Improvements(may also be included in building so obtain a breakdown), Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, Property of Others

Replacement Value of Building, if applicable ($)

Replacement Value of Computer Hardware ($)

Valuable Papers ($)

Property Used at Exhibitions, Fairs or Tradeshows ($)

Other property or equipment (specify what) ($)

Business Property Used/Transported/Stored Off-Premises ($)

Replacement Value of Other Office Contents ($)

General Liability

Each Occurrence Limit Desired ($)

Estimated Annual Gross Revenues ($)

Estimated Annual Total Payroll ($)

Number of Full Time Employees

Number of Part Time Employees

Do you use sub-contractors?

Yes

If yes, for what purposes?

Do you require sub-contractors to carry insurance and do you obtain certificates of insurance?

Yes

Worker's Compensation by State

State

Classification/Duties

Est. Annual Payroll ($)

Number of Employees

Owner/Officer Information

Name

Title

Duties

Incl/Excl

Automobile

Comprehensive Deductible ($)

Collision Deductible ($)

Rented Vehicles used or Employee Vehicles Used in Business?

Yes

If yes, number of rental car days/year

If non-owned, how many employees drive their cars frequently for company business

If any key employees have company vehicles and do not buy a personal auto policy for their protection while driving for personal use (Drive Other Car Coverage ), list their names

Owned Vehicle Schedule

NOTE: You may complete with Vehicles and Drivers below, or fax us your list at 301-417-0040

YEAR

MAKE / MODEL

COST NEW

GARAGING CITY/STATE

RADIUS

USE in YEARS

Drivers Schedule (if you own vehicles)

(List all employees who drive any vehicle on company business)

NAME

DATE OF BIRTH

DRIVERS LIC #

STATE

ACCIDENTS/VIOLATIONS WITHIN LAST 3 YEARS

Prior Claim/Loss Information

Have you had any prior claims or losses?

Yes

IMPORTANT: IF YOU ANSWERED YES ABOVE, PLEASE CALL YOUR CURRENT AGENT AND REQUEST A COPY OF YOUR CLAIMS HISTORY (OR “LOSS RUNS”) FOR THE LAST THREE YEARS FOR ALL OF YOUR POLICIES.

Other Optional Coverage to Consider

Do you need coverage for trips or work outside the United States?

Yes

Would you like an optional Umbrella Quote?

Yes

Would you like an Employee Benefits Quote (health, life, disability, long-term care)?

Yes

Would you like an Employment Practices Liability Quote?

Yes

Interested in Any Other Coverage Not Shown Above?