AI Software Insurance Underwriting Application

AI Software

Insurance Underwriting Application
This application form is designed to gather key information about your business. You must disclose all details that may be relevant to the coverage you are seeking, as this information will influence the underwriters’ decision to provide insurance, the scope of coverage offered, and the premium applied.
How to complete this form
The individual who completes this application form should be a senior member of staff at the company and should ensure that they have checked with other senior managers and colleagues responsible for arranging the insurance.
Section 1: Company Details

1.1 Please state the name and address of the principal company for whom this insurance is required. Cover is also provided for subsidiaries of the principal company, but only if you include the data from all of these subsidiaries in your answers to all questions in this form.
Full Legal Name of Company
Registered Address (Address, Province, Postal Code, Country)

Street Address

Street Address Line 2

City & Country State / Province

Postal / Zip Code
Website Address
1.2 Date the business was established (MM/DD/YYYY):

MonthDayYear
Date

1.3 Please provide the following information in respect of all subsidiaries that you have majority ownership of (more than 50% ownership) and state whether insurance is required for these subsidiaries as part of this application. If additional space is needed, provide this information in the Additional Information section.

Rows	Name	Date of acquisition / incorporation (if applicable)	Country of Domicile	Insurance Required? (Yes/No)
1.
2.
3.
4.

1.4 Please confirm if you are part of a corporate or other group structure where some parts of the group are not subject to this application for insurance (Y/N)
If yes, provide details
1.5 Date of company financial year end (MM/DD/YYYY)

MonthDayYear
Date

1.6 Please state your gross revenue in respect of the following years

Rows	Last Complete FY	Estimate for Current FY	Estimate for Next FY
Domestic Customer Revenue
USA Customer Revenue
Other Territory Customer Revenue
Total Gross Revenue

1.7 Payroll & Employee Count - Provide your current financial year payroll and employee count for Canada, US, and Foreign operations.

Rows	Total Employee Count
Canada
US
Foreign

Rows	Total Current Financial Year Payroll
Canada
US
Foreign

1.8 Please state whether in the next 12 months you have plans to make any significant changes to your business, such as changes in products or services, mergers, acquisitions, or divestitures (Y/N)
If yes, please provide full details here

1.9 Please provide the following details of any funding you have procured

Rows	Funding Round	Date of Round (MM/DD/YY)	Amount Raised
1.
2.
3.

Section 2: Activities
2.1 Please describe below the products and services supplied by your business

2.2 Please provide an approximate breakdown of how your revenue is generated from your products and services

Rows	Description of Product or Service	% of Sales
1.
2.
3.
4.
5.

2.3 Please state whether you:
(a) Are involved with the provision of any tangible products (Y/N)
If yes, confirm what percentage of your current year revenue this represents
(b)are involved with hardware installation at third party premises (Y/N)
If yes, confirm what percentage of your current year revenue this represents
2.4 Please state whether you provide hosting services to your clients (Y/N)
If yes, confirm whether this is hosted on your own infrastructure (Y/N)
Or by an outsourced service provider (Y/N)
If outsourced, state who is responsible for hosting and whether they are rated Tier 3 or better

2.5 Please provide a percentage breakdown of your products and services supplied to the following sectors

Rows	%
Automotive
Public Sector/Government
Financial Services
Military
Aerospace
Healthcare

2.6 Please confirm whether you provide any managed services (Y/N)
If yes please attach full details on a separate sheet.

Cancelof
Section 3: Contract & Risk Management Information

3.1 Please complete the following in respect of your three largest projects in the past three years

Rows	Name of Client	Nature of Work	Contract Start Date	Duration	Annual Contract Income	Overall Project Value
1.
2.
3.

3.2 Approximately how many customers do you have?

3.3 Please state the approximate percentage of engagements performed under your own contract versus customer-supplied contract

Rows	%
Own Contract
Customer-Supplied Contract

3.4 Please describe how, if at all, you limit your liability for consequential loss or financial damages
3.5 Please describe the impact on your clients if your products or services failed or you were unable to deliver your products or services
3.6 Do you employ subcontractors? (Y/N)
If yes, state the approximate percentage of your revenue in the current financial year that will be paid to subcontractors (%)
Section 4: Cyber Security Risk Management
4.1 Who within your organization is responsible for cybersecurity oversight and incident management?
4.2 Do you maintain formal cybersecurity, incident response, business continuity, and disaster recovery plans? (Y/N)
4.3 Please describe the key cybersecurity controls utilized across your environment, including endpoint protection, monitoring, detection, and threat response capabilities
4.4 Do you perform regular vulnerability scanning, patch management, and penetration testing? (Y/N)
4.5 Is multi-factor authentication (MFA) enabled for remote access, email, privileged accounts, and externally accessible systems? (Y/N)
4.6 Please describe your controls for securing cloud environments, production systems, APIs, and other externally accessible infrastructure
4.7 Do you maintain segregated and/or immutable data backups and regularly test restoration procedures? (Y/N)
4.8 Please describe your procedures for responding to cybersecurity incidents, prolonged outages, or failures involving critical systems or third-party providers
4.9 Do you provide mandatory cybersecurity and phishing awareness training to employees? (Y/N)
4.10 Please describe how you manage cybersecurity risk associated with third-party vendors, outsourced providers, and cloud platforms
4.11 Please describe the type and approximate volume of sensitive, confidential, or personal information stored, processed, or accessible through your systems
4.12 Do you encrypt sensitive or confidential information both at rest and in transit? (Y/N)
4.13 Please describe your software development, testing, and change management procedures, including controls governing production deployments
Section 5: Intellectual Property Rights Risk Management
5.1 Please describe below your procedures for managing intellectual property, including but not limited to your procedures for: (a) preventing the infringement of third-party intellectual property rights; (b) obtaining licenses to use and monitoring third-party intellectual property rights; and (c) responding to allegations of infringement
5.2 Please state whether you have ever sent or received the following relating to intellectual property rights: (a) a cease and desist letter; (b) notification of an actual or potential claim letter. If yes, please provide full details
5.3 Please confirm whether you intend to introduce any new products or to market any existing products in a new business sector or territory over the next 12 months. (Y/N)
5.4 Do your contracts provide indemnity to others related to third-party intellectual property infringement? (Y/N)
If yes, please provide details
Section 6: Insurance Requirements

6.1 Coverage Type

Rows	Effective Date	Coverage Limit
Technology Errors & Omissions
Cyber/ Network Security Liability
General Liability
Intellectual Property Infringement
Cyber Crime

Section 7: SaaS / AI Integration
7.1 Describe your AI products/services and whether outputs influence operational, financial, legal, healthcare, industrial, or other real-world decisions
7.2 Do you develop proprietary AI models, fine-tune third-party/open-source models, or rely on third-party hosted models? (Y/N)
If yes, describe the primary models used and any material licensing restrictions
7.3 Do you rely on third-party AI models, APIs, open-source software, orchestration tools, or external datasets? (Y/N)
If yes, describe key dependencies and related controls, including contingency planning
7.4 Describe your controls governing the collection, use, retention, licensing, and deletion of training data and customer data
7.5 Do you utilize web scraping, automated data collection, or third-party online data sources? (Y/N)
If yes, describe related legal/compliance controls
7.6 Can customers fine-tune, retrain, modify, or deploy agents/models within your environment? (Y/N)
If yes, describe segregation and monitoring controls
7.7 Does your technology integrate with robotics, autonomous systems, industrial controls, IoT devices, manufacturing systems, or other physical operations?
7.8 Do you assume contractual obligations relating to uptime, model performance, indemnities, IP infringement, service credits, or liquidated damages?
7.9 Do you provide customers with any indemnities relating to AI-generated outputs, model performance, training data, or intellectual property infringement?
7.10 Describe your controls for AI governance, including testing, monitoring, access controls, logging, incident response, and rollback capabilities
7.11 Have you received any claims, demands, or allegations relating to AI outputs, IP infringement, training data, web scraping, open-source licensing, or unauthorized data use?
Section 8: Additional Information
Please use this space below to provide us with any other relevant information
Section 9: Claims Experience
9.1 Please state whether you are aware of any incident: (a) which may result in a claim under any of the insurance for which you are applying to purchase in this application form; (b) which resulted in legal action being made against any of the companies to be insured within the last 5 years. (Y/N)
If yes, please describe the incident, including the monetary amount of the potential claim or the monetary amount of any claim paid or reserved for payment by you or by an insurer. Please include all relevant dates, including a description of the status of any current claim which has been made but has not been settled or otherwise resolved
9.2 Describe any prior cybersecurity incidents, ransomware events, data breaches, operational outages, cease and desist letters, indemnity requests, regulatory inquiries, or material security events involving your organization within the past five years
Section 10: Property Appendix
Please Only Complete This Section if Property Coverage is Required.

Copy this appendix if more than one premises is to be insured.
10.1 Premises Address (Address, Province, Postal code, Country)

Street Address

Street Address Line 2

City & CountryState / Province

Postal / Zip Code
10.2 Amounts to be insured

NOTE: The insured amounts entered below should reflect the full cost of rebuilding or replacing each category. If these amounts are understated, your coverage may be insufficient and full claim payments may not be made. It is therefore important that the values provided accurately represent the true replacement costs of the insured items

Rows	$
Building Coverage
Tenants Improvements
Inventory/Stock
Loss of Income
Indemnity Period for Loss of Income/Rent (Months)
Computer Equipment
Portable Equipment
Other Business Contents
Loss of Rent

10.3 Premises Details
a) When the premises was built (MM/DD/YY)

MonthDayYear
Date
b) When it was last renovated (MM/DD/YY)

MonthDayYear
Date
c) Construction type
d) When the roof was last renovated (MM/DD/YY)

MonthDayYear
Date
e) Roof construction
f) Percentage of flat roof
g) Floor construction
h) Whether the premises is detached (Y/N)
Security and Premises Details) Exterior/interior cameras (Y/N)
i) Area free from flooding (Y/N)
j) Heating method is one of electric/gas/oil/solid fuel (Y/N)
Notes
Keep records of inspections as evidence may be required before paying a claim. If any answers above are "no", provide further details
Important Notice
By signing this form you agree that the information provided is both accurate and complete and that you have made all reasonable attempts to ensure this is the case by asking the appropriate people within your business. This information will be used solely for the purposes of providing insurance services and may be shared with third parties in order to do this. Anonymized elements of your data may also be used for the analysis of industry trends and to provide benchmarking
data.
Contact Name:
Position:
Signature
Date (MM/DD/YYYY)

MonthDayYear
Date
View our privacy policy.
Should be Empty:

AI Software

Section 1: Company Details

Section 2: Activities

Section 3: Contract & Risk Management Information

Section 4: Cyber Security Risk Management

Section 5: Intellectual Property Rights Risk Management

Section 6: Insurance Requirements

Section 7: SaaS / AI Integration

Section 8: Additional Information

Section 9: Claims Experience

Section 10: Property Appendix