RefID ObjectType SourceID QuestionType ListCode ListOptionValue

1 Page
2 View
3 Question 10000001 Text
4 Question 10023001 Text
BusClassTag BusClassId CarrierId LobId QuestionText/ListOptionDisplayValue
Your Company
Your Company
What is the zip code of your primary business location?
What's the name of your business?
Required ShowTitle Condition Notes Controller TipCode
no
8759001 - STR Pucks: Zip Code
RefID ObjectType SourceID QuestionType ListCode ListOptionValue BusClassTag BusClassId
1 Page
2 View
3 Label
4 Question 260001 CheckBox
5 Question
261001
CheckBox
6 Question 271001 CheckBox
7 Question 264001 CheckBox
8 Question 262001 CheckBox
CarrierId LobId QuestionText/ListOptionDisplayValue Required ShowTitle Condition
Your protection
Your protection no
What type of insurance do you need?
General Liability and Business Property
Umbrella (Excess Liability)
Commercial Auto Liability (Business owned autos)
Professional Liability / Errors and Omissions
Workers' Compensation / Employers' Liability
Notes Controller TipCode
Hint
Language
Hint
Language
Hint
Language Hint
Language
Hint Hint
Language
RefID ObjectType SourceID QuestionType ListCode ListOptionValue BusClassTag
1 Page
2 View
3 Label
4 Question 101001 Date
5 Label
6 Question 134001 Integer
7 Question 135001 Integer
8 Label
9 Question 103005 Money
10 Question 103003 Money
11 Question 103001 Money
12 Label
13 Question 976006 Money
14 Question 2183001 Money
BusClassId CarrierId LobId
QuestionText/ListOptionDisplayValue
Business Basics
Business Basics
Company History
What date did your business begin?
Employees
How many people work for your business? (total staff, including yourself, owners, officers, employees, and contractors)
Of these _ people, how many are owners or officers?
Revenue
What will your revenue be for the next fiscal year?
What is your revenue for the current fiscal year? (current revenue)
What was your revenue in the prior fiscal year? (prior revenue)
Annual Payroll
What is the total annual payroll for your entire office?
What is the annual payroll for owners and officers?
Required ShowTitle Condition Notes
no
If qid 134001 > 1
If Years in Bus from qID 101001 is >1
If Years in Bus from qID 101001 is >1
If qid 134001 > 1
TipCode
RefID ObjectType SourceID QuestionType ListCode
1 Page
2 View
3 Client's Property c.PrimaryContact.FirstName Text
4 Client's Property c.PrimaryContact.LastName Text
5 Client's Property c.PrimaryContact.EmailAddr Text
6 Client's Property c.PrimaryContact.PhoneNumber Text
7 Question 105001 Integer
8 Question N#247001 CheckBox
9 Client's Property c.PrincipalContact.FirstName Text
10 Client's Property c.PrincipalContact.LastName Text
11 Question 10028001 Radio List N#SoonStart
12
13
14
ListOptionValue BusClassTag BusClassId CarrierId LobId QuestionText/ListOptionDisplayValue
Your information
Your information
Your first name
Your last name
Email
Contact phone number
How many years experience does the business owner
have?
Check here if you are the owner
Owner's First Name:
Owner's Last Name:
How soon do you need coverage to start?
ASAP ASAP
NEXT30 Next 30 days
MORE30 More than 30 days from now
Required ShowTitle Condition Notes
no
Default qID 247001 to 'Yes'
If no to qID 247001
If no to qID 247001
Controller TipCode
RefID ObjectType SourceID QuestionType ListCode
1 Page
2 View
3 Question 165001 Yes/No
4 Label
5 Label
6 Label
7 Client's Property c.PrimaryAddress.Address1 Text
8 Client's Property c.PrimaryAddress.City Text
9 Client's Property c.PrimaryAddress.StateAbbr Text
10 Client's Property c.MailingAddress CheckBox
11 Client's Property c.PrimaryAddress.SqFeet Integer
12 Question c.PrimaryAddress.OwnRent Radio List RentOwn
13
14
15 Question c.PrimaryAddress.ConstType Radio List BuildingType
16
17
18
19
20 Question c.PrimaryAddress.NumStores Integer
21 Question
171001
Integer
22 Label
23 Client's Property addr.PlumbingUpdateYear Year
24 Client's Property addr.WiringUpdateYear Year
25 Client's Property addr.RoofingUpdateYear Year
26 Client's Property addr.HeatingUpdateYear Year
27 Question addr.FireSprinkler Yes/No
28 Question addr Yes/No
29 Question addr Yes/No
30 Question addr Yes/No
31 Question addr Yes/No
32 Question addr Yes/No
33 Client's Property c.PrimaryAddress.UsePrimaryMailing CheckBox
34 Question ma.Address1 Text
35 Question ma.City Text
36 Question ma.StateAbbr State
37 Question ma.ZipCode Integer
38 Label
39 Button
40 Label
42 Button
43 Client's Property c.addr Yes/No
44 Client's Property c.Addresses[n].Address1 Text
45 Client's Property c.Addresses[n].City Text
46 Client's Property c.Addresses[n].StateAbbr State
47 Client's Property c.Addresses[n].ZipCode Integer
48 Client's Property c.addr Text
49 Client's Property c.addr Radio List RentOwn
50
51
52 Client's Property c.addr Radio List BuildingType
53
54
55
56
57 Client's Property c.addr Integer
58 Client's Property c.addr Year
59 Label
60 Client's Property addr.PlumbingUpdateYear Year
61 Client's Property addr.WiringUpdateYear Year
62 Client's Property addr.RoofingUpdateYear Year
63 Client's Property addr.HeatingUpdateYear Year
64 Client's Property c.addr Yes/No
65 Client's Property c.addr Yes/No
66 Client's Property c.addr Yes/No
67 Client's Property c.addr Yes/No
68 Client's Property c.addr Yes/No
69 Client's Property c.addr Yes/No
ListOptionValue BusClassTag BusClassId CarrierId LobId
Own
Rent
GL, PROP, BOP
FR
MNC
MY
FRM
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
PROP, BOP
PROP, BOP
PROP, BOP
PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
Own
Rent
GL, PROP, BOP
FR
MNC
MY
FRM GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
PROP, BOP
PROP, BOP
PROP, BOP
PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
GL, PROP, BOP
QuestionText/ListOptionDisplayValue Required ShowTitle
Your Locations
Your Locations no
Is your business based in your home?
Primary Business Address
Home Address
We must have a physical address to provide a quote (not a P.O. Box).
Address:
City:
State:
Use this address as my mailing address
Square feet of space used for business at the address above:
Do you own or rent?
Own
Rent
Building construction is: (Place cursor over each item for a sample of each building
type.)
High rise building six stories or more
low rise building five stories or less with steel, glass and/or concrete construction
low rise brick or concrete block construction, typically built before 1970
low rise wood structure, may have brick exterior. Includes residential
Number of stories in this building:
Year the building was built:
Please state when updates were made to the following:
Plumbing _____
Wiring______
Roofing_____
Heating_____
Does the building have a fully protected and operational sprinkler system covering
100% of the building?
Do you have a Functioning and operational smoke and/or heat detectors in all units
and/or occupancies?
Does the building have aluminum or knob & tube wiring?
Is all of the electrical wiring is connected to functioning and operational circuit
breakers?
Is the building you occupy currently damaged by fire or otherwise?
Is the building partially constructed?
Use this address as my mailing address
Address:
City:
State:
Zip:
Other Business Addresses
Add Another Location
Business Adderss #[n]
Remove Location
Is your business based in your home?
Address:
City:
State:
Zip:
Square feet of space used for business at the address above:
Do you own or rent?
Own
Rent
Building construction is: (Place cursor over each item for a sample of each building
type.)
High rise building six stories or more
low rise building five stories or less with steel, glass and/or concrete construction
low rise brick or concrete block construction, typically built before 1970
low rise wood structure, may have brick exterior. Includes residential
Number of stories in this building:
Year the building was built:
Please state when updates were made to the following:
Plumbing _____
Wiring______
Roofing_____
Heating_____
Does the building have a fully protected and operational sprinkler system covering
100% of the building?
Do you have a Functioning and operational smoke and/or heat detectors in all units
and/or occupancies?
Does the building have aluminum or knob & tube wiring?
Is all of the electrical wiring is connected to functioning and operational circuit
breakers?
Is the building you occupy currently damaged by fire or otherwise?
Is the building partially constructed?
Condition Notes Controller
If No to qID 165001
If NO to qID 165001
Default to "Yes"
If QID 171001 older 25 years
If QID 171001 older 25 years
If QID 171001 older 25 years
If QID 171001 older 25 years
If QID 171001 older 25 years
If qID 171001 > 1978
If qID 171001 > 1978
If No to qID 165001 Own selected
If No to qID 165001 Own selected
If 'No' to Use this address as my mailing address (qID c.MailingAddress)
If 'No' to Use this address as my
mailing address (qID
c.MailingAddress)
If 'No' to Use this address as my
mailing address (qID
c.MailingAddress)
If 'No' to Use this address as my
mailing address (qID
c.MailingAddress)
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected
qID
If 'Add Another Location' is selected qID
If QID 171001 older 25 years
If QID 171001 older 25 years
If QID 171001 older 25 years
If QID 171001 older 25 years
If QID 171001 older 25 years
If qID 171001 > 1978
If qID 171001 > 1978
TipCode
HighRise
LowRiseSteel
LowRiseBrick
LowRiseWood
If 'No' to Use this address as my mailing address (qID c.MailingAddress)
RefID ObjectType SourceID QuestionType ListCode
1 Page
2 View
3 Question 269001 DropDown List GLCoverageAmount
4
5
6 Label
7 Question 3032001 Yes/No
8 Question 3033001 DropDown List GL_EPLAmount
9
10
11
12
13
14
15
16 Question 3096001 Yes/No
17 Label
18 Question 3097001 Date
19 Question 3098001 Text
20 Question 3099001 DropDown List
GL_EPLI_Prior_Limit_Hartford
21
22
23
24
25
26
27
28
29 Question 223001 Date
30 Question 3101001 Yes/No
31 Question 3102001 Yes/No
32 Question 3103001 Yes/No
33 Question 3104001 Yes/No
34 Question 3105001 Yes/No
35 Question 3106001 Yes/No
36 Question 3107001 CheckBox List EPL_EmploymentPolicie
37
38
39
40
42 Question 3108001 CheckBox List EPL_EmploymentPolicie
43
44
45
46
47 Label
48 Question 3034001 Yes/No
49 Question 3035001 DropDown List GL_DataBreachResponseExpenses
50
51
52
53
54 Question 3036001 DropDown List GL_DataBreachDefenseLiability
55
56
57
58
59 Question 3087001 CheckBox List DataBreach_TypesOfClient
60
61
62
63
64
65
66
67
68
69 Question 3088001 CheckBox List DataBreach_ComputerSystemsProte
ction
70
71
72
73
74
75 Question 3089001 CheckBox List DataBreach_PoliciesInplace
76
77
78
79
80
81 Question 3090001 CheckBox List DataBreach_TypesOfEquipment
82
83
84
85
86
87
88 Question 3091001 Yes/No
90 Question 3092001 CheckBox List DataBreach_ProtectPersonallyIdentif
iable
91
92
93
94
95
96 Question 3093001 CheckBox List DataBreach_CreditCardsType
97
98
99
100
101
102 Question 3094001 Text
103 Question 3095001 CheckBox List DataBreach_CardInfPurged
104
105
106
107
108
109 Question 506001 CheckBox
110 Label
111 Question 1102001 DropDown List BOPCoverageAmount
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132 Question 8107001 DropDown List OADeductible
133
134
135
136
137
138
139 Label
140 Label
141 Question 1120001 DropDown List OfficeCoverage_Computers
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162 Label
163 Question 10225001 CheckBox List MedEquipType
164
165
166
167
168
169
170 Question 10226001 DropDown List CTScans
171
172
173
174
175
176
177 Question 10227001 DropDown List CTScansGEModel
178
179
180
181
182
183
184 Question 10228001 DropDown List CTScansNeuroModel
185
186
187
188
189
190 Question 10229001 DropDown List CTScansPhilipsModel
191
192
193
194
195
196 Question 10230001 DropDown List CTScansSiemensModel
197
198
199
200
201
202
203 Question 10231001 DropDown List CTScansToshibaModel
204
205
206
207
208
209 Question 10232001 DropDown List NumberSlices
210
211
212
213
214
215 Question 10233001 Text
216 Question 10234001 DropDown List ManufMRI
217
218
219
220
221
222
223 Question 10235001 DropDown List GEMRI
224
225
226
227
228
229
230 Question 10236001 DropDown List HitachiMRI
231
232
233 Question 10237001 DropDown List PhilipsMRI
234
235
236
237
238 Question 10238001 DropDown List SiemensMRI
239
240
241
242 Question 10239001 DropDown List ToshibaMRI
243
244
245 Question 10239001 DropDown List MagnetPower
246
247
248
249
250 Question 10241001 Text
251 Question 10242001 Text
252 Question 10243001 Yes/No
253 Question 10244001 CheckBox List MedEquipApply
254
255
256
257
258
259
260
261
262 Question 10244001 Yes/No
263 Label
264 Question 270001 Yes/No
265 Question 577001 Yes/No
266 Question 576001 Yes/No
267 Question 1121001 Yes/No
268 Label
269 Question 273001 DropDown List AutoPersonalHowOften
270
271
272 Question 1122001 Integer
273 Question 1123001 Radio List AutoPersonalRadiusOfOperation
274
275
276
277 Question 1124001 CheckBox List AutoPersonalEmployeesInvolvedIn
278
279
280
281
282
283
284 Question 1121001 Text
285 Question 1126001 Integer
286 Label
287 Question 272001 DropDown List HowOftenRented
288
289
290
291
292
293 Question 1127001 CheckBox List AutoPersonalControlMeasures
294
295
296
297 Label
298 Question 507001 DropDown List UM_Liability_Coverage
299
300
301
302
303
304 Label
305 Question 3013001 Yes/No
306 Question 3014001 Yes/No
307 Question 3015001 Yes/No
308 Question 3016001 Yes/No
309 Question 3017001 Yes/No
310 Question 3018001 Yes/No
311 Question 3019001 CheckBox List AlliedHealth_StorageContainers
312
313
314
315 Question 3020001 Integer
316 Question 3021001 Integer
317 Question 3022001 Text
318 Question 3023001 Text
319 Question 3024001 Yes/No
320 Question 3025001 Yes/No
ListOptionValue BusClassTag BusClassId CarrierId LobId
67
67
67
1000000|2000000 67
2000000|4000000 67
67
67
67 100. 108 GL, BOP
10000
25000
50000
100000
250000
500000
1000000
67
67 100. 108 GL, BOP
67 100. 108 GL, BOP
67 100. 108 GL, BOP
67 100. 108 GL, BOP
25000|25000
50000|50000
100000|100000
100000|200000
250000|250000
500000|500000
1000000|1000000
Other
67 100. 108 GL, BOP
67 100. 108 GL, BOP
67 100. 108 GL, BOP
67 100. 108 GL, BOP
67 100. 108 GL, BOP
67 100. 108 GL, BOP
67 100. 108 GL, BOP
67 100. 108 GL, BOP
EmploymentApplication
EmploymentAtWill
HRpolicies
None
67 100. 108 GL, BOP
TrackingClaim
PerformanceEvaluations
TerminationsByHR
None
67 100 GL, BOP
67 100 GL, BOP
67 100 GL, BOP
10000
25000
50000
100000
67 100 GL, BOP
50000
100000
250000
500000
67 100 GL, BOP
CreditCardNumbers
SSN
DOB
DriversLicenseNumbers
MedicalData
LegalData
FinancialData
Email
None
67 100 GL, BOP
Password GL, BOP
Firewalls GL, BOP
Antivirus GL, BOP
DataSecurityByVendor GL, BOP
None GL, BOP
67 100 GL, BOP
CriminalBackgroundCheck GL, BOP
WrittenPolicy GL, BOP
AccessDBJob GL, BOP
RestrictedAccess GL, BOP
None GL, BOP
67 100 GL, BOP
SmartPhones
ExHDD
ThumbDrive
Laptop
Tablet
None
67 100 GL, BOP
67 100 GL, BOP
PasswordProtection
Encryption
Fingerprint
DataErasure
None
67 100 GL, BOP
AmericanExpress
Discover
MasterCard
Visa
Other
67 100 GL, BOP
67 100 GL, BOP
AfterTransactiond
OneMonth
SixMonths
AfterSixMonths
NotApply
110, 200
110, 200
1000
5000
10000
20000
25000
30000
40000
50000
60000
70000
80000
90000
100000
125000
150000
175000
200000
300000
400000
500000
110, 200
250
500
1000
2500
5000
10000
110, 200
110, 200
110, 200
10000 110, 200
15000 110, 200
25000 110, 200
50000 110, 200
75000 110, 200
100000 110, 200
125000 110, 200
150000 110, 200
200000 110, 200
250000 110, 200
275000 110, 200
300000 110, 200
325000 110, 200
350000 110, 200
375000 110, 200
400000 110, 200
425000 110, 200
450000 110, 200
475000 110, 200
500000 110, 200
110, 200
67 303, 906 110, 200
CTScans
CAT Scans
MRI
LinearAcceleratorsRadiationT
herapy
Lithotripters
None
67 303, 906 110, 200
Unknown 110, 200
GeneralElectric 110, 200
Neurologica 110, 200
Philips 110, 200
Siemens 110, 200
Toshiba 110, 200
67 303, 906 110, 200
Unknown 110, 200
AllModels 110, 200
Brightspeed 110, 200
Discovery 110, 200
LightSpeed 110, 200
Optima 110, 200
67 303, 906 110, 200
Unknown 110, 200
AllModels 110, 200
BodyTomCore 110, 200
CereTomCore 110, 200
CereTomOTOScanCore 110, 200
67 303, 906 110, 200
Unknown 110, 200
AllModels 110, 200
Brilliance 110, 200
Ingenuity 110, 200
MX 110, 200
67 303, 906 110, 200
Unknown 110, 200
AllModels 110, 200
DefinitionAS 110, 200
DefinitionFlash 110, 200
Emotion 110, 200
Spirit 110, 200
67 303, 906 110, 200
Unknown 110, 200
AllModels 110, 200
Aquilion 110, 200
Definition 110, 200
Emotion 110, 200
67 303, 906 110, 200
Unknown 110, 200
2-8 110, 200
16-20 110, 200
32-64 110, 200
128-320 110, 200
67 303, 906 110, 200
67 303, 906 110, 200
Unknown 110, 200
GeneralElectric 110, 200
Hitachi 110, 200
Philips 110, 200
Siemens 110, 200
Toshiba 110, 200
67 303, 906 110, 200
Unknown 110, 200
AllModels 110, 200
Discovery 110, 200
Optima 110, 200
SignaHD 110, 200
SignaVibrant 110, 200
67 303, 906 110, 200
Unknown 110, 200
Echelon 110, 200
67 303, 906 110, 200
Unknown 110, 200
AllModels 110, 200
Achieva 110, 200
Ingenia 110, 200
67 303, 906 110, 200
Unknown 110, 200
AllModels 110, 200
Magnetum 110, 200
67 303, 906 110, 200
Unknown 110, 200
Vantage 110, 200
67 303, 906 110, 200
Unknown
1_0_Tesla
1_5_Tesla
3_0_Tesla
67 303, 906 110, 200
67 303, 906 110, 200
67 303, 906 110, 200
67 303, 906 110, 200
UPS
SurgeProtection
FullMaint
PurchasedUsedRefurbished
GreaterThan10yo
ProtectedFSS
SmokeDetectors
None
100, 200
100, 200
100, 200
100, 200
100, 200
100, 200
100, 200
100, 200
0-3
3+
100, 200
100, 200
0|50
51|200
200+
100, 200
Delivery
OutsideSales
RoutineErrands
TimeConstraints
StudentTransportation
Other
100, 200
100, 200
100, 200
100, 200
OCCASIONALTRAVEL
LESSTHANONCEPERWEEK
SEVERALTIMESPERWEEK
Other
None
100, 200
PersonalAutoLimits
MvrOnFile
MaintainMinLimits
1000000|1000000
2000000|2000000
3000000|3000000
4000000|4000000
5000000|5000000
100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
S1
S2
None
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
67 303, 448, 906 100 100, 110,
200
QuestionText/ListOptionDisplayValue Required ShowTitle Condition
General Liability & Property Policy
General Liability & Property Policy no
Please indicate the amount of general liability
coverage you require:
$1,000,000/$2,000,000
$2,000,000/$4,000,000
Employment Practices Liability
Do you want your quote to include coverage for
Employment Practices Liability? (Coverage to
respond to allegations such as discrimination,
wrongful termination or sexual harassment of
employees.)
Please indicate the amount of Employment
Practicies Liability coverage you require:
if qid 3032001 = yes
$10,000 (Built-In)
$25,000
$50,000
$100,000
$250,000
$500,000
$1,000,000
Do you currently carry Employment Practices
Liability (EPLI) coverage?
if qid 3032001 = yes
Please provide the following regarding your
current EPLI coverage:
if qid 3096001 = yes
Policy Effective Date: if qid 3096001 = yes
Insurance Carrier: if qid 3096001 = yes
Limit of EPLI coverage: if qid 3096001 = yes
$25,000 / $25,000
$50,000 / $50,000
$100,000 / $1000
$100/000 / $200,000
$250,000 / $250,000
$500,000 / $500,000
$1,000,000 / $1,000,000
Other Limit
EPLI Retroactive Date: if qid 3096001 = yes
Have you maIntegerained continuous EPLI coverage
from the Retroactive Date above to the present?
if qid 3096001 = yes
Have you had a workforce reduction of greater than
25% in any 2 of the past 3 years?
if qid 3032001 = yes
Do the insured anticipate a workforce reduction of
greater than 25% in the next year?
if qid 3032001 = yes
Do greater than 25% of your employee's have salary
equal to or greater than $100,000?
if qid 3032001 = yes
How many employment related claims,
administrative proceedings, EEOC action letters or
attorney letters have you experienced in the past
three years?:
if qid 3032001 = yes
Is any person proposed for coverage aware of any
fact or circumstance or any actual or alleged act,
error or omission which might give rise to a claim
that would fall within the scope of the proposed
coverage?
if qid 3032001 = yes
Please indicate which of the following written
employment related policies are in place and easily
accessible for all employees to reference:
if qid 3032001 = yes
A written employment application
An employment-at-will statement
An employee handbook or HR policies/procedures
None of the Above
Please indicate which of the following written
employment related policies are in place and easily
accessible for all employees to reference:
if qid 3032001 = yes
A written procedure for reporting and tracking claim
and incident information is in place
Regular written performance evaluations of all
employees are conducted
Requires all terminations to be reviewed by Human Resources or Legal Counsel
None of the above
Data Breach
Do you want your quote to include Data Breach
coverage? (Provides coverage for loss cause by a
breach of personally identifiable information)
Data Breach - Response Expenses (such as
notification expenses, crisis management expenses,
monitoring services, good faith advertising, and
legal/forensic services)
if qid 3034001 = yes
$10,000
$25,000
$50,000
$100,000
Data Breach - Defense & Liability (coverage for civil
awards, settlements and judgments as a result of a
Data Breach claim that you are legally obligated to
pay)
if qid 3034001 = yes
$50,000
$100,000
$250,000
$500,000
Which of the following types of client/customer
information do you store electronically or in files,
process or transmit?
if qid 3034001 = yes
Credit or debit card numbers
Social security numbers
Date of birth
Drivers license numbers
Client medical data/records
Client legal data/records
Client financial data/records
Email addresses
None of the above
Which of the following do you have in place on all
of your computer systems e.g. servers, laptops,
networks unless otherwise noted?
qID 3087001 is anything EXCEPT
None
Password protection
Firewalls
Antivirus Software
Computer network data security functions are
performed by an outside vendor.
None of the above
Which of the following procedures/policies do you
have in place?
if qid 3087001 =MedicalData,
LegalData, FinancialData
Criminal employee background check at hiring
Written Privacy policy
Access to data based on job function
Immediate restricted access to data upon employee
termination
None of the Above
Which of the following procedures/policies do you
have in place?
if qid 3087001 =MedicalData,
LegalData, FinancialData
iPhone, BlackBerry, or other Smart Phones
External hard drive
Thumb drive
Laptop
iPad or Tablet type device
None of the above
Do you store, process, transfer or transmit
personally identifiable information such as social
security numbers, credit or debit card info, client
legal, medical or financial information on these
mobile devices or equipment?
qID 3090001 is anything EXCEPT
None
Which of the following steps has the insured taken
to protect personally identifiable information on
these devices or equipment?
If qID 3090001 = yes
Implemented use of passcode/password protection
Implemented encryption of files and emails on all
equipments
FingerprInteger access required
Data erasure enabled
None of the above
Which of the following credit or debit cards is your
payment processing equipment authorized to
process transactions for?
American Express
Discover
MasterCard
Visa
Other
Please describe other credit or debit cards, and
provide the names of the insured's payment card
processing companies.
How often is credit or debit card information
purged from your systems?
Immediately after transaction is processed
Within one month of transaction
Within six months of transaction
Some or all information is retained for more than six
months Does not apply as no electronic cardholder data
storage
Check here to decline coverage for your computers
and other office contents. (Note: When your policy
does not include coverage for your property, there
Office Address If qID 506001 = Yes
Office contents coverage:(Coverage for your
business personal property such as furniture, desks,
chairs, and office supplies, that are primarily used in
your business.)
$1,000
$5,000
$10,000
$20,000
$25,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
$125,000
$150,000
$175,000
$200,000
$300,000
$400,000
$500,000
Deductible If qID 506001 = Yes
$250
$500
$1,000
$2,500
$5,000
$10,000
Optional Coverage: Select the coverage options
you are Integererested in below: (Please select all
that apply)
If qID 506001 = Yes
Please provide the dollar amount required to
completely replace each property listed below.
These figures should represent the amount required
to replace the property at current costs.
If qID 506001 = Yes
Computers & Media (including PC's, peripherals,
software, etc.)
If qID 506001 = Yes
$10,000
$15,000
$25,000
$50,000
$75,000
$100,000
$125,000
$150,000
$200,000
$250,000
$275,000
$300,000
$325,000
$350,000
$375,000
$400,000
$425,000
$450,000
$475,000
$500,000
Medical Equipment
Which of following types of medical equipment does
the facility have? (Check all that apply)
If qID 506001 = yes
Computerized Tomography Scanners (CT Scans)
Computerized Axial Tomography Scanners (CAT
Scans)
Magnetic Resonance Imaging Scanners (MRI)
Linear Accelerators or any other external bean of
radiation therapy
Lithotripters
None of the above
Select Manufacturer of Computerized Tomography
Scanners (CT Scans):
if qid 10225001 = CTScans
Unknown
General Electric
Neurologica
Philips
Siemens
Toshiba
Select General Electric Model of Computerized
Tomography Scanners (CT Scans):
if qid 10226001 = GeneralElectric
Unknown
All Models
Brightspeed
Discovery
LightSpeed
Optima if qid 10226001 = CTScans
Select Neurologica Model of Computerized
Tomography Scanners (CT Scans):
if qid 10226001 = Neurologica
Unknown
All Models
BodyTom Core
CereTom Core
CereTom OTOScan Core
Select Neurologica Model of Computerized
Tomography Scanners (CT Scans):
if qid 10226001 = Philips
Unknown
All Models
Brilliance
Ingenuity
MX
Select Siemens Model of Computerized Tomography
Scanners (CT Scans):
if qid 10226001 = Siemens
Unknown
All Models
Definition AS
Definition Flash
Emotion
Spirit
Select Siemens Model of Computerized Tomography
Scanners (CT Scans):
if qid 10226001 = Toshiba
Unknown
All Models
Aquilion
Definition
Emotion
Select Number of Slices of Computerized
Tomography Scanners (CT Scans):
if qid 10226001 = CTScans
Unknown
2-8
16-20
32-64
128-320
Describe the Computerized Tomography Scanners
(CT Scans):
if qid 10225001 = CTScans
Select Manufacturer of Magnetic Resonance
Imaging Scanners (MRI):
if qid 10225001 = MRI
Unknown
General Electric
Hitachi
Philips
Siemens
Toshiba
Select General Electric Model of Magnetic
Resonance Imaging Scanners (MRI):
if qid 10234001 = GeneralElectric
Unknown
All Models
Discovery
Optima
Signa HD
Signa Vibrant
Select General Electric Model of Magnetic
Resonance Imaging Scanners (MRI):
if qid 10234001 = Hitachi
Unknown
Echelon
Select Phillips Model of Magnetic Resonance
Imaging Scanners (MRI):
if qid 10234001 = Philips
Unknown
All Models
Achieva
Ingenia
Select Siemens Model of Magnetic Resonance
Imaging Scanners (MRI):
if qid 10234001 = Siemens
Unknown
All Models
Magnetum
Select Toshiba Model of Magnetic Resonance
Imaging Scanners (MRI):
if qid 10234001 = Toshiba
Unknown
Vantage
Select Magnet Power of Magnetic Resonance
Imaging Scanners (MRI):
if qid 10225001 = MRI
Unknown
< 1.0 Tesla
1.5 Tesla
3.0 Tesla
Describe the Magnetic Resonance Imaging Scanners
(MRI):
if qid 10225001 = MRI
Provide the details of medical equipment selected: If qid 10225001 = Linear, Lithotrupters, CAT
Is any of this medical equipment (CT Scans, CAT
scans, MRIs, Linear Accelerators or Lithotripters)
normally moved to other locations using a vehicle or
other motorized means?
If qid 10225001 = Linear, Lithotrupters, CAT, MRI, 'CT Scan'
Which of the following apply to CT Scans, CAT Scans,
MRIs, Linear Accelerators, or Lithotripters? (Check
all that apply)
If qid 10225001 = Linear, Lithotrupters, CAT, MRI, 'CT Scan'
UnIntegererrupted power supply (UPS)
Surge Protection
Full maIntegerenance contract (not just Time and
Material contract)
Purchased used/refurbished
Greater than 10 years old
Protected by an automatic fire suppression system
Smoke/Heat detectors
None of the above
Does your facility follow the American College of
Radio Listlogy (ACR) Safe MR Practices?
if qid 10225001 = MRI
Auto Liability
Do you have any vehicles commercially owned/titled to your business?
Would you like a quote for Commercial Auto coverage? If qID 270001 = yes
Do you want your quote to include coverage for Hired/Non-Owned Auto Liability? If qID 270001 = no
Do you have a commercial auto policy in force? If qID 576001 = yes
Personal Vehicles Used in Business
How often do your employees use their personal
vehicle on company business?
If qID 576001 = yes
Occasionally
More than 3 times a week
How many of your employees regularly (more than
3 times a week) use their personal autos as part of
If qID 273001 = '+3'
What is the maximum radius of operation? If qid 1122001 > 0
Local (0 to 50 miles)
Integerermediate (51 to 200 miles)
Long distance (more than 200 miles)
Employees who drive are involved in (please check
all that apply).
If qID 576001 = yes
Delivery
Outside Sales
Routine Errands
Time ConstraIntegers
Student or Youth Transportation
Other
Please Describe 'Other' If qid 1124001 = 'Other'
How many of the employees regularly using their
personal autos are 25 years of age or younger?
If qID 576001 = yes
Rented Vehicles Used in Business
How often do you or your employees rent vehicles
on company business?
Occasional out of town travel
Less than once per week
Several times per week
Other
None of the Above
Please indicate the control measures in place (Check
all that apply).
Employees carry personal auto insurance liability
limits of at least 100/300/50
($100,000/$300,000/$50,000 split) or $300,000 CSL
Drivers' MVRs are on file and checked annually by
insured
Require all employees & volunteers who operate
their personal autos on behalf of your organization
to maIntegerain minimum state financial
Umbrella Liability
Please indicate the amount of umbrella liability
coverage you require:
If qID 261001 = yes
$1,000,000/$1,000,000
$2,000,000/$2,000,000
$3,000,000/$3,000,000
$4,000,000/$4,000,000
$5,000,000/$5,000,000
Hazardous Material/Waste Management
Has there been a discharge, dispersal or release of a
hazardous or regulated material or waste to air,
land or water from your location since you've
owned or occupied it or prior to your ownership or
occupancy?
Has there been a discharge, dispersal or release of a
hazardous or regulated material or waste to air,
land or water at any off premises locations due to
your operations.
Is your firm required under any federal or state
statute or regulation (e.g. SARA Title III), to report or
disclose the presence of one or more hazardous
materials?
Is your site or your operation in any form of
environmental remediation?
Is your firm required, under any federal or state
statute or regulation, to report or permit the
storage, discharge, treatment, or disposal of any
hazardous waste in any form, including but not
limited to solid wastes, liquid wastes and air quality
discharges?
Do you have any chemical, flammable or other
hazardous material (solid or liquid) on your
location?
Indicate which of the following storage containers
are utilized:
If qid 3018001 = yes
Above ground storage tanks
Underground storage tanks
None of the Above
Provide the age of the oldest above ground storage
tank(s).
If qid 3019001 = S1
Provide the total gallon capacity of all the above
ground storage tanks.
If qid 3019001 = S1
What is the construction of the above ground
storage tank?
If qid 3019001 = S1
Provide a description of the contents. If qid 3019001 = S1
Do you or others have hazardous materials stored,
in any form or manner, in or adjacent to your
business, in quantities that would exceed the
Threshold Planning Quantity of the US
Environmental Protection Agency ( 40 CFR 355 et
Are you aware of any claims or suits or potential
claims or suits regarding exposure to toxic
substances?
Notes Controller TipCode
New List Code and List
Values
Default to TRUE
If WebBusClass = 'Animal Hospital (27001)' or 'Veterinarian (27006)
UpDate ListCode Value
from E1 to value
UpDate ListCode Value
from E2 to value
UpDate ListCode Value
from E3 to value
UpDate ListCode Value
from E4 to value
UpDate ListCode Value
from E5 to value
UpDate ListCode Value
from E6 to value
If qid 10225001 = Linear, Lithotrupters, CAT
If qid 10225001 = Linear, Lithotrupters, CAT, MRI, 'CT Scan'
If qid 10225001 = Linear, Lithotrupters, CAT, MRI, 'CT Scan'
If BOP/GL/HNOA selected
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
If 'Animal Hospital
(27001)', 'Kennel (27002)'
or 'Veterinarians (27006)'
AND Primary State = IN,
LA or VT
ObjectTypeList: QuestionTypeList: YesNoList
Page Radio List yes
View Yes/No no
Question Yes/No/NA
Label Text
Service MultiText
Industry CheckBox
Button CheckBox List
Client's Property DropDown List
Integer
Money
Percent
Date
Phone
SSN
ZipCode
State
Year