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Short Form Internet Professional Liability Application

NOTICE: The policy providers that the limits of liability available to pay judgments or
settlements shall be reduced by amounts incurred for legal defense. Further note that amounts incurred for legal defense shall be applied against the deductible amount.

Name of Applicant:
Mailing Address:

Email address:
World Wide Web URL:

Limits of Desired Coverage:

$500,000 $1,000,000 $2,000,000
$3,000,000

$5,000,000

Deductible Amount:

$5,000 $10,000 $25,000 $50,000

Total Annual Gross Revenues:

(if projected, please note)

Where are the above listed revenues derived from?
On-line Publishing	%
Web Site Designing/Maintenance	%
Search Engines	%
Software Development (Pre-Packaged)	%
Internet Access Provider Services (No Content)	%
Web Site Hosting/Directories	%
Software Development (Custom)	%
Internet Access Provider Services (With Content)	%
Encryption Software/Firewall Software	%
Internet Access Provider Services (Content, E-Mail, BBS, Chat Rooms)	%
Internet Security Consulting	%
Other Non-Related (please explain)	%

If you provide Internet Access, how many subscribers do you currently have?

Do you provide origional content on the Internet?

Yes No

Have you ever received a complaint concerning the content of your Web Site or Internet Service relevant to any of the following: Libel or Slander , Trademark Infringement, Invasion of Privacy, Copyright Infringement, Inaccurate Information or Obscene/Pornographic Content?
Yes No

Do you obtain all licenses and consents for all works which you make available on the Internet Service, including music and film clip or still images?
Yes No

Does the applicant or any of its Officers, Directors or Partners, or their Counsel, have any knowledge, actual or constructive:
(a) of any claims or legal proceedings made or commenced against the Applicant, or any Officers, Directors Partners, or subsidiary or affiliated corporations within the last five (5) years?
Yes No

(b) of any potential claim or circumstances that might give rise to a claim against the Applicant or any Officers, Directors, Partners of subsidiaries or against any other person, firm or corporation arising out of or based upon the Internet Services provided by the Insured that would be covered by the Policy sought to be obtained by the Applicant?
Yes No

Contact Person at your Company:

Application Submission Options:

Option One:

Now that you have completed your short form Internet
Professional Liability Application, you may submit it
electronically for a tentative premium quotation by pressing
the submit button below. We will return a premium quotation
to you via e-mail within a short time.

Option Two: If you wish to obtain a firm premium quotation you will need to accomplish the following:

Call Poulton Associates at (801) 268-2600 and
request a full Internet Professional Liabilities
Application from a member of our staff.
Attach to the application you most recent audited financial statement.
Attach to the application any descriptive promotional materials.
Attach to the application a copy of a standard service contract or a recent contract issued.
If the company has been established for three years or less, please provide resumes of senior professional staff

Mail all of this to us at the address shown in the
"How to Contact Us" section below.
We will provide you with a firm quotation within a short time.

How to Contact Us
You can:

Use our short inquiry form .
Send e-mail to service@poulton.com
Check for other services.
Or call or write, to