Welcome to Holman Insurance Brokers on-line IT Errors & Omissions Insurance quick quote page. Please ensure you complete the form as accurately as possible in order to ensure the best possible estimate. If you would rather speak to one of our sales representatives, please call us at (905) 886-5630 or 1-800-567-1279.

Completion of this form is for informational purposes only, and is just an estimate.
This WILL NOT result in a new policy, or change to an existing policy.

* Required Fields

Contact Information
Company Name*
Contact First Name*
Address*
Contact Last Name*
City*
Phone*
Province*
Phone 2
Postal Code*
Fax
Web Site
E-Mail*
Please specify your preferred method of contact:
Phone Email
Company Information
Years in Business
Type of business
Describe the major business activities of the organization
As shown from the last Annual Statement or Report, please indicate:
Authorized Capital
Paid Up Capital
Total Sales Turnover
Pre-tax Profit
Number of Employees
Number of Certified Professionals
Desired Limit
$
Desired Deductible
$
Insurance Information (Provide the following information for all Errors & Omission policies in the past 5 years)
Information
Policy 1
Policy 2
Policy 3
Insurer
Limit
Deductible
Effective From
Retro Date
Expiry Date

Has your Professional Insurance ever been cancelled, declined or not renewed? Explain: Yes No

Are you aware of any circumstances which could become the basis of a claim? Explain:   Yes No
What is your current annual premium?
$
Why are you looking for a new insurer or broker?
Revenues
Percentage from Information Technology Services
Year Products or Services First Sold
Data Conversion
%
Data Processing
%
Systems Analysis
%
Systems Design
%
Systems Integration
%
Software Design
%
Consulting
%
Other (specify)
%
Revenues from Manufacturing / Distribution
Hardware
Power Related Equipment
Software
Other (specify)
Semi Conductors
Other (specify)
Revenues from Internet Related Services
Access Provider
News Groups
E-Mail Hosting
Chat Rooms
Web Design / Hosting
Advertising
Content Provider
Application Hosting
e Commerce Sales
Other (specify)

Please indicate the nature of content you provide on the internet (ie. advertising, financial, contests, etc.):

Please describe a typical customer and list any clients that generate more than 10% of your revenue:

Please list any new products and / or services to be launched within the next 12 months:

If you have discontinued any products or services in the past 3 years, please explain:
What is the percentage of revenue derived from customized work?       %
Quality Control
Do you require a signed final acceptance from your customers?
Yes No
Do you maintain written records of client complaints?
Yes No

Please explain what service and response times you gaurantee to your customers:

What insurance requirements do you impose on (or assume from) your subcontractors?
Is there a formal recall program presently in place?
Yes No

If you have ever recalled a product, please give the details:
Do you have a formal disaster recovery plan?
Yes No

What is the worst thing that could happen to your customers' operations if your products or services were to fail, or cease to work?
Contractual Information
Do you use a standard contract?
Yes No
Do your contracts contain the following clauses?
Force Majeure
Yes No
Disclaimer of Warranties
Yes No
Limitation of Warranties
Yes No
Limitation of Liabilities
Yes No
Conditions of Product Acceptance
Yes No
Hold Harmless or Indemnity Agreements
Yes No
Specific Description of Services / Products Supplied
Yes No
Who has the ultimate responsibility for contract wordings in your company?
Do you ever assume liability for consequential loss over and above the replacement of the products or services, or the refund of any paid fees?
Yes No

If yes, please provide full details:
Additional Comments



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Thank you for trusting Holman Insurance Brokers Ltd. for your insurance needs, one of our representatives will contact you soon with your quote!
IT E&O Quote