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Home › AI liability › Application

Guided application

AI liability insurance application

Complete what applies. If you are unsure of a technical answer, choose Unknown - a licensed specialist reviews every application before markets are approached.

1Company and coverage
2AI systems
3Governance and loss history
4Contracts
5Review and certify

Your answers are saved as a draft in this browser on this device so you can return later. They include sensitive underwriting details - avoid using a shared or public device.

Company fax

Step 1 of 5

Company and coverage

Company full legal name *

Company website

Number of employees

Industry and NAICS code

Company addressStreet, city, state and ZIP.

Annual revenue

Gross profit or net revenue

In one sentence, what does your company do, and roughly how many customers?

Coverage areas of interest

Output errors IP infringement and personal injury Unauthorized data disclosure Bodily injury Property damage Regulatory violations

Requested policy limit

Step 2 of 5

AI systems

Step 3 of 5

Governance and loss history

You maintain an AI usage policy available to employees defining acceptable and prohibited uses

You have not altered or removed any guardrails or safety mechanisms set by the AI vendor

You clearly disclose to third parties that they are interacting with or relying on AI outputs

You have not deployed AI for any use prohibited by privacy or AI-specific laws

Your public privacy notices have been reviewed by legal counsel and you obtain necessary consents where AI processes protected information

Summarize any demands, lawsuits or regulatory investigations related to your use of generative AI - or write None.

Step 4 of 5

Contracts

Average customer contract value

Largest customer contract value

What share of your contracts use your standard terms?

Does qualified legal counsel draft or review your standard and customized contracts?

How is your contractual liability capped?

Liability cap valuePercentage or dollar amount.

Which provisions do your customer contracts include?

Limitation of liability Hold harmless or indemnity benefiting you Binding arbitration Disclaimer of warranties Exclusion of consequential damages AI output accuracy or performance disclaimers

Step 5 of 5

Review and certify

What other insurance policies do you carry?

You can supply copies of your agreements with each AI vendor

Names and job titles of those responsible for AI governance

I declare that, to the best of my knowledge and belief after reasonable inquiry, the statements in this application are true and complete. I understand this application does not bind coverage, that it will be relied on in underwriting, and that I must report any material change before a policy begins.

Applicant name *

Position or title

Applicant email *

Signature - type your full name *

Signature date

NOTICE TO ALL APPLICANTS: Any person who knowingly, and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or, for the purpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insurance act which is a crime and subjects such person to criminal and civil penalties in many states.

An independent commercial insurance agency placing the full business suite. Our cyber specialty practice trades as BlackFire Cyber Insurance.

Coverage

Cyber and technology
Professional and management liability
Property and casualty
Cyber liability
Technology E&O
D&O
General liability
Life Insurance & Retirement

Firm

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Headquarters Atlanta, GA

BlackFire Insurance is an independent insurance agency, not an insurer. We do not underwrite policies or make coverage determinations. Cover is placed with third-party insurance carriers and is subject to their underwriting, terms, conditions and exclusions. Descriptions of coverage on this site are general summaries for information only and do not amend, extend or alter any policy. The policy issued by the insurer governs in all cases. BlackFire Insurance and its producers are licensed in the states where services are offered. Licence numbers are available upon request. Availability, eligibility and coverages may vary by state, and not all products are available in all states.

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