eHealth Application Form | Insurance Center of North Jersey

Section 1: Company Details

1.1 Please state the name and 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.

Company name:*

Primary address (address, state, zip code, country):

Street Address State / Province / Region ZIP / Postal Code

Website

1.2 Date the business was established (MM/DD/YYYY):

1.3 Number of employees:

1.4 Please state your gross revenue in respect of the following years:

Domestic revenue:

Last complete financial year

Estimate for current financial year

Estimate for next financial year

Other territory revenue:

Last complete financial year

Estimate for current financial year

Estimate for next financial year

Total gross revenue:

Last complete financial year

Estimate for current financial year

Estimate for next financial year

Profit (Loss):

Last complete financial year

Estimate for current financial year

Estimate for next financial year

Date of company financial year end (MM/DD/YYYY):

1.5 Please provide details for the primary contact for this insurance policy

Contact name:

Position:

Email address:

Telephone number:

Section 2: Activities

2.1 Please describe in detail 1) the nature and types of professional and/or technology services you are engaged in and 2) the types of technology products developed, manufactured, licensed or sold:

2.2 Please state whether your technology services are used for diagnosis, treatment or prevention of diseases or other conditions?

Yes
No

2.3 Please provide an approximate breakdown of how your revenue is generated from your products and services:

1

%

2

%

3:

%

4 :

%

5 :

%

6 :

%

7 :

%

2.4 Please indicate the estimated number of patient encounters for the next 12 months:

2.5 Please provide a full breakdown of your services offered by province or state (the total of all activities should equal 100%)

AL (%):

AK (%):

AZ (%):

AR (%):

CA (%):

CO (%)

CT (%):

DE (%):

FL (%):

GA (%):

HI (%):

ID (%):

IL (%):

IN (%):

IA (%):

KS (%):

KY (%):

LA (%):

ME (%):

MD (%):

MA (%):

MI (%):

MN (%)

MS (%):

MO (%):

MT (%):

NE (%)

NV (%):

NH (%)

NJ (%):

NM (%):

NY (%):

NC (%):

ND (%):

OH (%):

OK (%)

OR (%):

PA (%)

RI (%):

SC (%):

SD (%):

TN (%):

TX (%):

UT (%):

VT (%):

VA (%)

WA (%):

WV (%)

WI (%):

WY (%):

territories (%)

Other (%)

Total (%

2.6 Please state whether all professionals are subject to background checks (criminal, federal, state, sexual offender registry etc.)

Yes
No

If “no”, please provide details:

2.7 Please state whether any physician has had a board action brought against them in the last 5 years:

Yes
No

If “yes”, please provide details:

2.8 Please state whether medications are prescribed through your services:

Yes
No

Section 3: Contract & Risk Management Information

3.1 Please complete the following in respect of your 3 largest projects in the past 3 years:

1) Name of client:

Nature of your work undertaken:

Your annual income from this contract:

Duration:

2) Name of client:

Nature of your work undertaken:

Your annual income from this contract:

Duration:

3) Name of client:

Nature of your work undertaken:

Your annual income from this contract:

Duration:

3.2 Please state approximately how many customers you have:

3.3 Please state whether you always carry out work under a written contract signed by every client

Yes
No

3.4 Please describe how, if at all, you limit your liability for consequential loss or financial damages under a written contract:

3.5 Please describe your legal review process, if any, before entering into new contracts or agreements:

3.6 Please describe the impact on your clients if your products or services failed or you were unable to deliver your products or services:

3.7 Do you employ subcontractors?

Yes
No

If “yes”, please state:

a) what approximate percentage of your revenue, in your current financial year, will be paid to subcontractors (%)

b) whether you sign reciprocal hold harmless agreements

Yes
No

c) whether you ensure that subcontractors have their own errors and omissions and general liability insurance:

Yes
No

d) if you answered “yes” to c) above, what is the limit of liability that subcontractors must purchase:

Section 4: Cyber Security Risk Management

4.1 Please describe the type of sensitive information you hold (including PII/PHI) and provide an approximate number of unique records that you store or process:

4.2 Please describe the most valuable data assets you store:

4.3 Please state whether you are compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPPA)

Yes
No

4.4 Please tick all the boxes below that relate to companies or services where you store sensitive data or who you reply upon to provide critical business services:

4.5 Please tick all the boxes below that relate to controls that you currently have implemented within your IT infrastructure (including where provided by a third party). If you’re unsure of what any of these tools are, please refer to the explanation on the final page of this document. business services:

Please provide the name of the software or service provider that you use for each of the control highlighted above:

Section 5: Intellectual Property Rights Risk Management

5.1 Please describe below your procedures for: a) preventing infringing on third party intellectual property rights; and b) obtaining licenses to use and the monitoring of third party intellectual property rights:

5.2 Please state whether you have ever sent or received the following relating to intellectual property rights:

a) a cease and desist letter:

Yes
No

b) notification of an actual or potential claim letter

Yes
No

If “yes” to a) or b) above, please provide full details:

5.3 Please describe your procedures for managing intellectual property rights issues, including responding to an allegation of infringement and how the individual responsible for intellectual property rights issues is qualified for the role

Section 6: Claims Experience

6.1 Please state whether you are aware of any incident

a) which may result in a claim under any of the insurance for which you are applying to purchase in this application form

Yes
No

b) which resulted in legal action being made against any of the companies to be insured within the last 5 years:

Yes
No

If you have answered “yes” to a) or b) above then please describe the incident, including the monetary amount of the potential claim or the monetary amount of any claim paid or reserved for payment by you or by an insurer. Please include all relevant dates, including a description of the status of any current claim which has been made but has not been settled or otherwise resolved.

Section 7: Additional Information

Please provide the following information when you send the application form to us.

• Directors or principals resumes if the company has been trading for less than 3 years;

• The organization chart or group structure if any subsidiaries are to be insured including names, dates of acquisition, countries of domicile, percentages of ownership; and

• The standard form of contract, end user license agreement or terms of use issued by the company

Name:

Date of Acquisition:

Country of Domicile:

Percentage of ownership:

Name:

Date of Acquisition:

Country of Domicile:

Percentage of ownership:

Name:

Date of Acquisition:

Country of Domicile:

Percentage of ownership:

Please provide this space below to provide us with any other relevant information:

Important notice

By signing this form you agree that the information provided is both accurate and complete and that you have made all reasonable attempts to ensure this is the case by asking the appropriate people within your business. CFC Underwriting will use this information solely for the purposes of providing insurance services and may share your data with third parties in order to do this. We may also use anonymized elements of your data for the analysis of industry trends and to provide benchmarking data. For full details on our privacy policy please visit www.cfcunderwriting.com/privacy

Contact Name:

Position:

Date (MM/DD/YYYY)

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