{"id":1995,"title":"PROPOSAL FORM PROFESSIONAL INDEMNITY (TECHNOLOGY) INSURANCE","purpose":"proposal","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/13-professional-indemnity-(technology)-insurance8c0007ff45fd68ff8a0df0055fa61787.pdf","sha256":"d8f3cb8c35ec2e008d9ebdaaad403f03054362b8f1376dd44b7ebbec7220b04a","pages":6,"collected":"2026-10-20","instructions":{"about":"This form is used by individuals or entities seeking professional indemnity insurance coverage for technology-related risks. The proposer (applicant) fills it out to provide necessary information for underwriting the insurance policy.","notes":["Answer all questions completely and accurately; write 'NA' if a question does not apply.","Insurance is a contract of utmost good faith; disclose all material facts.","Insurance is not effective until proposal is accepted and premium received.","If the proposal form is filled by a person other than the proposer or proposer signs in vernacular or is illiterate, a declaration by the person explaining the form is required.","Use additional sheets if needed to provide full information.","Contact ICICI Lombard customer support for any clarifications."],"title":"PROPOSAL FORM PROFESSIONAL INDEMNITY (TECHNOLOGY) INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"post / e-mail / upload","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064.\nE-mail: customersupport@icicilombard.com"},"purpose":"proposal","sections":[{"title":"Proposer Details and Contact Information","fields":[{"help":"Provide your current and permanent address.","type":"text","label":"Present & Permanent Address","options":[],"required":null,"pdf_field":""},{"help":"Name of the authorized person if nominee is a minor.","type":"text","label":"Authorized person for Minor Nominee","options":[],"required":null,"pdf_field":""},{"help":"Provide bank details for refund of premium if applicable.","type":"text","label":"Bank Details","options":[],"required":null,"pdf_field":""},{"help":"List other insurance policies covering the same risks, if any.","type":"text","label":"Details of Multiple/Other insurance covering same risks with any other Insurance Company","options":[],"required":null,"pdf_field":""},{"help":"Select the type of proposer.","type":"choice","label":"Type of Proposer","options":["Individual","Partnership firm","MSME/SME","Company","Govt.","Others"],"required":null,"pdf_field":""},{"help":"Choose if you want physical copies of policy documents.","type":"choice","label":"Do you wish to avail policy documents in physical form","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of the nominee for the policy.","type":"text","label":"Nominee Name","options":[],"required":null,"pdf_field":""},{"help":"Relationship of nominee to the insured.","type":"text","label":"Relationship with the Insured","options":[],"required":null,"pdf_field":""},{"help":"Provide mobile phone number.","type":"phone","label":"Mobile No.","options":[],"required":null,"pdf_field":""},{"help":"Provide email address.","type":"email","label":"Email ID","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Business and Contract Details","fields":[{"help":"Enter percentage value.","type":"number","label":"What percentage of the policyholder and subsidiary's business comes from repeat clients?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do the policyholder and subsidiary have written contracts with all clients?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Answer only if previous question is No.","type":"yes-no","label":"If 'No', does legal counsel review all customized contracts or agreements & marketing materials prior to release?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do all contracts with customers fully describe the scope of services to be provided?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do all contracts include how any disputes between the policyholder/subsidiary and the clients will be handled?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Select one option.","type":"choice","label":"Please / the correct option form below for the policyholder and subsidiary's Hold harmless or indemnity agreements:","options":["They inure to the policyholder/subsidiary's benefit","They inure to the client's benefits","They are mutual"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do all the policyholder and subsidiary's contracts carry a Limitation of Liability clause?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do all the policyholder and subsidiary's contracts carry Guaranties or Warranties?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company negotiate contracts or agreements in which it accepts liability for consequential damages?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Provide average contract value in currency.","type":"amount","label":"What is the value of average contract or agreement?","options":[],"required":null,"pdf_field":""},{"help":"Provide average duration (e.g. months, years).","type":"text","label":"What is the average tenure of contract or agreement?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is client sign off required on pilot tests run prior to regular production?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are performance milestones acknowledged with client sign off?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are interim changes documented with client sign off?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do clients have responsibility for determining the accuracy of results?","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Sub-Contracting","fields":[{"help":"","type":"yes-no","label":"Does the Company sub-contract any Professional Services?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Describe the type of subcontracted work.","type":"text","label":"If 'Yes': What type of work is sub-contracted?","options":[],"required":null,"pdf_field":""},{"help":"Enter percentage value.","type":"number","label":"What percentage of total work is subcontracted?","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Network Protection","fields":[{"help":"","type":"yes-no","label":"Do the policyholder and subsidiaries have a written and formalized network security policy statement in place?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are all security threats and incidents logged and investigated?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the disaster recovery program and business continuity plan formalized and tested?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do the policyholder and subsidiaries have antivirus software on all computer devices, servers and networks which are updated in accordance with the software providers' recommendations?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do the policyholder and subsidiaries have firewalls and intrusion monitoring detection in force to prevent unauthorized access?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are all employees assigned specified rights, privileges and unique user ID and passwords, which are changed periodically?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do the policyholder or subsidiary provide remote access to its Computer Systems?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Provide number of users with remote access.","type":"number","label":"If 'Yes', how many users have remote access?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is all valuable/sensitive data backed-up by the policyholder subsidiaries every day?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Explain exceptions if data is not backed up daily.","type":"text","label":"If 'No' please describe exceptions:","options":[],"required":null,"pdf_field":""},{"help":"Provide duration of backup tape storage.","type":"text","label":"How long are back-up tapes stored before being overwritten?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the policyholder or any subsidiary suffered unauthorized access of its Computer Systems in the past twelve (12) months?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Number of unauthorized access incidents.","type":"number","label":"If 'Yes', how many intrusions occurred?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do policyholder and subsidiaries conduct training for every employee user of the information systems security issues and procedures for its Computer Systems?","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Industry and Activity Revenue Split","fields":[{"help":"Enter percentage for each industry: Aviation, Media, BFSI, Retail, Education, Telecommunications, Energy & Utilities, Transportation & Logistics, Health Care, Others, Manufacturing. Total must be 100%.","type":"table","label":"Please provide the following Industry wise split of the policyholder or subsidiary's consolidated revenues","options":[],"required":null,"pdf_field":""},{"help":"Enter percentage for each activity: Application Maintenance, Hardware Sales, Application Development, Systems Installation, BPO, Systems Maintenance, Data Processing and Entry, Training, Custom Software Development, Other (explain), Consultancy. Total must be 100%.","type":"table","label":"Please provide the following Activity -wise split of the Company's consolidated revenues (excluding other income)","options":[],"required":null,"pdf_field":""},{"help":"List client name, professional service provided, and revenue percentage.","type":"table","label":"Please provide the following details of the clients that represent more than five percent (5%) of revenues","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Privacy Exposures","fields":[{"help":"","type":"yes-no","label":"Do the policyholder or subsidiaries collect, maintain or process personal information of clients?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Describe types of personal information collected.","type":"text","label":"If 'Yes', please indicate the type of information which is collected and stored?","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Do the policyholder and subsidiaries have legally reviewed privacy policy in place to comply with laws governing the handling and/or disclosure of such information?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the policyholder have a designated privacy officer who has responsibility for meeting the policyholder and subsidiary's worldwide obligation under privacy and data protection laws?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company share private or personal information gathered from customers with Consultants or third parties?","options":["YES","NO"],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Refund of Premium Bank Details","fields":[{"help":"Name of bank account holder for premium refund.","type":"text","label":"Account Holder Name","options":[],"required":null,"pdf_field":""},{"help":"Name of the bank.","type":"text","label":"Bank Name","options":[],"required":null,"pdf_field":""},{"help":"Bank account number.","type":"text","label":"Account No.","options":[],"required":null,"pdf_field":""},{"help":"Bank IFSC code for electronic transfers.","type":"text","label":"IFSC Code","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer"},{"title":"Declarations and Signatures","fields":[{"help":"Full name of the proposer.","type":"text","label":"Name of the Proposer","options":[],"required":true,"pdf_field":""},{"help":"If filled by someone other than proposer, specify relationship.","type":"text","label":"Relationship with Proposer","options":[],"required":null,"pdf_field":""},{"help":"Address of the witness signing the form.","type":"text","label":"Address of Witness","options":[],"required":null,"pdf_field":""},{"help":"Full name of the witness.","type":"text","label":"Name of the Witness","options":[],"required":null,"pdf_field":""},{"help":"Signature of the proposer or authorized person.","type":"signature","label":"Signature of Proposer","options":[],"required":true,"pdf_field":""},{"help":"Signature of the witness.","type":"signature","label":"Signature of Witness","options":[],"required":null,"pdf_field":""},{"help":"Place where the form is signed.","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing the form.","type":"date","label":"Date","options":[],"required":true,"pdf_field":""}],"filled_by":"proposer and witness"}],"deadlines":["Inform ICICI Lombard immediately of any change in information before policy issuance.","Undertake to inform any changes in details immediately, not later than 30 days."],"applies_to":"Professional Indemnity (Technology) Insurance","attachments":["If additional space is required to provide relevant information, attach a separate sheet.","Attach any documents supporting the proposal as required."],"declarations":["The proposer declares that all information provided is true, complete and accurate and no material facts are withheld.","The proposer consents to verification of identity and address proofs through Central KYC Registry or UIDAI or other modes.","The premium has been paid from legally acquired sources and future premiums will be paid similarly.","The proposer understands that failure to disclose material facts may lead to claim rejection or policy avoidance.","The proposer agrees to abide by all terms and conditions of the insurance policy.","The proposer understands the statutory warning about prohibition of rebates under Section 41 of Insurance Act 1938."],"dropped_labels":0},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/icici-lombard-general-insurance/1995-proposal-form-professional-indemnity-technology-insurance"}