Technology Errors & Omissions Liability Application - FailSafe MEGA®

The words You, Your and Yours in this application mean all of the following: the Named Applicant below (the "Applicant"); all subsidiaries in which the Applicant has more than a 50% ownership interest; and all officers, directors, owners, partners and employees of the aforementioned entities. The words We, Us, and Our mean the Insurer.

Contact Information

("Applicant", "you", "yours" and "your" include any person or entity for whom this insurance is intended):

Coverage Information

Please note that additional underwriting information (i.e. copy of a typical customer contract signed by the applicant or financials) may be requested based on the information provided within this application including limit requests of $2M / $2M or greater.
Indicate which of the following Technology Products or Services (includes all consulting services) are offered by the applicant to others? (select all that apply) Please checkmark all of the appropriate boxes that represent the operations you provide to your customers
Software, Communication, and Connectivity Products/Services
Hardware Products/Services
Other Products/Services
Do the end user(s) of the applicant's products, software, or services involve any of the following: (only select those operations which apply) The end user is your client that is utilizing your products or services
Please indicate the estimated percentage of time the applicant utilizes the following in their engagements with customers:
%
%
%
%
Please provide the following information on the applicant's customers & contracts:
$
$
APPLICANT STATEMENT:
I, being duly authorized, have read the above application and declare to the best of my knowledge and belief all of the foregoing statements are true, and that these statements are offered as an inducement to the Company to issue the policy for which I am applying. (Kansas: This does not constitute a warranty).


First State Insurance Company (N/A in MA) New England Reinsurance Corporation (N/A in MA)
Hartford Accident and Indemnity Company Nutmeg Insurance Company (N/A in MA)
Hartford Casualty Insurance Company Omni Indemnity Company (N/A in MA)
Hartford Fire Insurance Company Omni Insurance Company (N/A in MA)
Hartford Insurance Company of Illinois (N/A in MA) Pacific Insurance Company, Limited (N/A in MA)
Hartford Insurance Company of the Midwest Property and Casualty Insurance Company of Hartford
Hartford Insurance Company of the Southeast (N/A in MA) Sentinel Insurance Company, Ltd.
Hartford Lloyd's Insurance Company (N/A in MA) Trumbull Insurance Company (N/A in MA)
Hartford Underwriters Insurance Company Twin City Fire Insurance Company
New England Insurance Company (N/A in MA)