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Quote Request Form


THOROUGHLY COMPLETE THIS APPLICATION, IT WILL SPEED UP THE PROCESS!!
IT SHOULD ONLY TAKE 5-10 MINUTES

Contact Information - Part 1 of 4
Business Name  
Contact Name  
Title  
Address  
City  
Zip Code  
State  
County  
Country  
Phone Number  
Alternate Phone Number  
Fax Number  
E-mail Address  
Domain Name  
Do you have a current or pending contract  
that requires proof of insurance?  
 Yes  No
Does your landlord require proof of insurance?  
 Yes  No
Proposed Start Date  
   MM/DD/YYYY

Business Property / Location - Part 2 of 4
Do you Rent?  
  Yes   No
or Do you Own?  
  Yes   No
Square Feet Occupied  
Square Feet in Building  
Construction type:  
Building information:  
 Year Built (Approx)
Number of Stories
 Residential
 Light Industrial
 Commercial/High-Rise
General office contents value  
(excluding computer hardware)  
 $
Business Computer-Hardware  
 $
Business Computer-Software  
 $
Property Off-Premises  
 $
Describe any property off-premises  
(Secondary business locations / POPs, CO-LO's)  
Burglar alarm?  
  Yes   No
Dead bolt locks?  
  Yes   No
Are adequate records kept?  
  Yes   No
Exterior Lighting Front & Back?  
  Yes   No
Do you back-up your information regularly?  
  Yes   No
Is the back-up kept off premises?  
  Yes   No
Do you regularly check for viruses?  
  Yes   No
About Your Business - Part 3 of 4
Type of Company  
Type of Business  
Date your company began under current ownership:  
  Month     Year   
FEIN/Tax/SS #  
Number of Principals  
Number of Technical Professional Staff  
Number of Clerical/Administrative Staff  
ESTIMATED Gross Receipts for next 12 months  
 $
Foreign sales receipts?  
  Yes   No
WEEKLY payroll  
Number of W2 Employees  
Number of 1099 subs  
Do you own any other businesses?  
  Yes   No

Please thoroughly explain, IN DETAIL  
the work your company performs, and  
whom you provide these services for?  

Please provide a brief example!

(Please do not just tell us "Computer Consultant")  

   
If you have been in business  
less than 3 years, Describe  
your experience and education:   
General Liability Limit Required:   
Umbrella Liability Limit Required:   
Number of vehicles owned by your business:   
In the last five years, have you had any claims?   
  Yes   No
If yes, please explain:   
Do you currently have either General Liability or Professional Liability in effect?  
  Yes   No
When does your policy renew?  
  Month     Year   

We will include a quotation for Professional Liablilty/ Errors & Omissions (if you qualify). This coverage MAY be required

Note: If you utilize any subcontractors, you should obtain Certificates of Insurance verifying they have limits of insurance equal to or greater than your own.
Are you designing software that involves any of the following:
     Military/Nuclear Software:  
  Yes   No
     Robotics or heavy machinery controls?  
  Yes   No
     Financial Institution Software?  
  Yes   No
     Automated Quality Control?  
  Yes   No
     Fire and Security, Alarm, warning or      remote sensing systems?
  Yes   No
     Heat, temperature or fluid level      monitoring?  
  Yes   No
     If "Yes", please explain in   detail:  
Percentages/Types of Services You Provide - Part 4 of 4
Based on LAST YEAR'S RECEIPTS, please provide
the percentages for each cateogry below.

(If new in business, please provide a projection)

THE TOTAL MUST EQUAL 100%      
     Internet Service Providers (ISPs)  
  %
     Wireless ISP  
  %
     Business Application Software Development  
  %
     Database Design/Management  
  %
     Systems Design/Administration/Engineering  
  %
     Network Design & Administration  
  %
     Software/Hardware Installation & Maintenance  
  %
     Software Sales  
  %
     Hardware Only Installation and Maintenance  
  %
     Hardware Sales  
  %
     Web Design, Development/Graphic Design  
  %
     Web Hosting  
  %
     Training & Education  
  %
     Technical Writing  
  %
     Telecommunications Consulting  
  %
     Application Service Provider  
  %
     E-Commerce  
  %
     Content/FTP/Search Service  
  %
     Firewalls / Protection  
  %
      Backup Services  
  %
     Manufacturing Software
     (Robotics, Automation, PLO, CAM, etc.)  
  %
     Medical Management
     (Patient Records, Billing, etc.)  
  %
     CAD (Non-structural)  
  %
     Medical Diagnostic Software/Hardware  
  %
     Staffing  
  %
     Accounting/Financial/Payroll Software  
     (no funds transfer)  
  %
     Financial Transaction Software  
     (EFT, Equity Trading, etc.)  
  %
     ERP Implementation   
       
  %
THE TOTAL MUST EQUAL 100%     

Is the software involved in executing financial transactions such as sale of stocks, currency exchange, credit card processing, ATM transfer, etc.? Please describe in detail the function or use of the software you have been or will be working on.
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