IRONSHORE SPECIALTY INSURANCE COMPANY · TECH.APP.001 (1216) Page: 3of 13 PRODUCTS AND SERVICES...
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IRONSHORE SPECIALTY INSURANCE COMPANY 75 State St. Boston, MA 02110 Toll Free: 877-IRON411 TechDefender® Long Form Application Tech E&O, Network Security, Privacy, Internet Media, and MPL Insurance Application TECH.APP.001 (1216) Page: 1 of 13 THE APPLICANT IS APPLYING FOR A CLAIMS MADE AND REPORTED POLICY, WHICH IF ISSUED, APPLIES ONLY TO CLAIMS FIRST MADE AGAINST THE INSURED AND REPORTED TO THE INSURER DURING THE POLICY PERIOD, OR, AS APPROPRIATE, TO THE APPLICABLE EXTENDED REPORTING PERIOD. CLAIM EXPENSES ARE PART OF AND NOT IN ADDITION TO THE LIMITS OF LIABILITY. THE PAYMENT OF CLAIM EXPENSES SHALL REDUCE THE LIMIT OF LIABILITY AVAILABLE TO PAY LOSS. PLEASE READ THE ENTIRE POLICY CAREFULLY. TECH E&O, NETWORK SECURITY, PRIVACY, INTERNET MEDIA, and MPL INSURANCE APPLICATION COMPLETION INSTRUCTIONS A. Please answer all the questions applicable to coverage for which you are applying. The information is required to make an underwriting and pricing evaluation. Your answers hereunder are considered legally material to the evaluation. B. If a question is not applicable, state N/A. If more space is required to answer a question, attach any additional explanatory exhibits and reference the application question number the exhibit corresponds to. C. The application must be signed by and dated by an authorized officer, partner or principal of the Applicant. PLEASE ALSO ATTACH THE FOLLOWING: A. Copy of your most recent advertising materials and product brochures; B. Copies of representative contracts and largest sales and/or licensing contracts; C. Copy of most recent financial statements (10K, annual report); D. Five (5) years of loss runs valued within the past six (6) months; E. List of all pending or threatened litigation GENERAL INFORMATION (For all Applicants) Applicant and Subsidiaries 1. Applicant Name (as it should appear on the policy, if written): 2. Address: City: County: State: Zip: Phone: Fax: 3. Policyholder Information Technology/Security Contact: Name: Title: Phone Number: E-mail: 4. Website Address(es): 5. Applicant is: Sole Proprietor Partnership LLC Corporation Joint Venture Other (describe): 6. Date Established:
Transcript of IRONSHORE SPECIALTY INSURANCE COMPANY · TECH.APP.001 (1216) Page: 3of 13 PRODUCTS AND SERVICES...
IRONSHORESPECIALTYINSURANCECOMPANY75StateSt.
Boston,MA02110TollFree:877-IRON411
TechDefender®LongFormApplication
TechE&O,NetworkSecurity,Privacy,InternetMedia,andMPLInsuranceApplication
TECH.APP.001 (1216) Page: 1 of 13
THEAPPLICANT ISAPPLYINGFORACLAIMSMADEANDREPORTEDPOLICY,WHICH IF ISSUED,APPLIESONLYTOCLAIMSFIRSTMADEAGAINSTTHEINSUREDANDREPORTEDTOTHEINSURERDURINGTHEPOLICYPERIOD,OR,ASAPPROPRIATE,TOTHEAPPLICABLEEXTENDEDREPORTINGPERIOD.CLAIMEXPENSESAREPARTOFANDNOTINADDITIONTOTHELIMITSOFLIABILITY.THEPAYMENTOFCLAIMEXPENSESSHALLREDUCETHELIMITOFLIABILITYAVAILABLETOPAYLOSS.PLEASEREADTHEENTIREPOLICYCAREFULLY.
TECH E&O, NETWORK SECURITY, PRIVACY, INTERNET MEDIA, and MPL INSURANCE APPLICATION COMPLETIONINSTRUCTIONS
A. Please answer all the questions applicable to coverage for which you are applying. The information is required to make anunderwritingandpricingevaluation.Youranswershereunderareconsideredlegallymaterialtotheevaluation.
B. Ifaquestionisnotapplicable,stateN/A.Ifmorespaceisrequiredtoansweraquestion,attachanyadditionalexplanatoryexhibitsandreferencetheapplicationquestionnumbertheexhibitcorrespondsto.
C. Theapplicationmustbesignedbyanddatedbyanauthorizedofficer,partnerorprincipaloftheApplicant.
PLEASEALSOATTACHTHEFOLLOWING:A. Copyofyourmostrecentadvertisingmaterialsandproductbrochures;B. Copiesofrepresentativecontractsandlargestsalesand/orlicensingcontracts;C. Copyofmostrecentfinancialstatements(10K,annualreport);D. Five(5)yearsoflossrunsvaluedwithinthepastsix(6)months;E. Listofallpendingorthreatenedlitigation
GENERALINFORMATION(ForallApplicants)ApplicantandSubsidiaries1. ApplicantName(asitshouldappearonthepolicy,ifwritten):
2. Address:
City: County: State: Zip:
Phone: Fax:
3. PolicyholderInformationTechnology/SecurityContact:Name:
Title:PhoneNumber:
E-mail:
4. WebsiteAddress(es):
5. Applicantis:
SoleProprietor Partnership LLC Corporation JointVenture
Other(describe):
6. DateEstablished:
TECH.APP.001 (1216) Page: 2 of 13
7. NumberofEmployees:
8. NumberofCustomers:
a. Individuals: c.Government:
b.Corporate: d.NotforProfit:
9. IndependentContractors: YesNo
a.Whatistheestimatedpercentofthetimetheyareused? %
b.Describetheservicestheyperform:
c.Numberofindependentcontractors:
10. Subsidiaries(ifany):
NameofEntity NatureofOperations %ofOwnership
%
%
%
11. AnnualRevenue:Domesticrevenue:Internationalrevenue:TotalRevenue:
LastCompleteFinancialYear
EstimateforCurrentFinancialYear
ProjectedforNextFinancialYear
$ $ $
$ $ $
$ $ $
12.RequestedCoverage:
CoveragePart(s)RequestedCoverage RequestedLimit
RequestedSIRorWaitingPeriod
RequestedRetroactiveDate
A.NetworkSecurityLiabilityCoverage YesNo $ $
B.PrivacyLiabilityCoverage YesNo $ $
C.PrivacyBreachExpenseCoverage YesNo $ $
D. RegulatoryFinesandProceedingsCoverage
YesNo $ $
E.InternetMediaLiabilityCoverage YesNo $ $
F.DigitalAssetExpensesCoverage YesNo $ $
G.BusinessInterruptionIncomeLossandDependentBusinessInterruptionIncomeLossCoverage
YesNo $ $
H.NetworkandDataExtortionThreat
RewardPaymentsCoverage
YesNo
YesNo
$
$
$
$
I.TechnologyErrorsandOmissionsCoverage
YesNo $ $
J.MiscellaneousProfessionalLiabilityCoverage
YesNo $ $
TECH.APP.001 (1216) Page: 3 of 13
PRODUCTSANDSERVICES (please completeQuestions15 through20 if TechnologyErrorsandOmissions Liabilitycoverageisbeingrequested).
13. IndicatetheindustriesfortheApplicant’sproducts/services:Providethepercentageofrevenueexpectedthisyearfromthefollowing.Pleasenotethatthetotalmustequalonhundredpercent(100%).
IndustryType %ofTotalRevenue
IndustryType %ofTotalRevenue
Agricultural/Environmental Healthcare/Medical
Aerospace Hospitality/Entertainment
Construction/Mining Manufacturing/Industrial
Data/PaymentProcessing Telecommunications
Education Trade(Retail/Wholesale)
Financial/Banking/Insurance Transportation
Government(military) Utilities
Government(non-military) Other
14. ProductorServiceType:Pleasenotethatthetotalmustequalonehundredpercent(100%).
TypeofProductorServices %ofCurrentYearRevenue %ofNextYearEstimatedRevenue
ApplicationServiceProvider
Co-locationServices
CustomSoftwareDevelopment
DataandTransactionProcessing
Hardware,Devices,Components–Installation,IntegrationandMaintenance
Hardware,Devices,Components-Manufacturing
HelpDeskServices
InformationTechnologyConsulting
InternetServiceProvider
OnlineExchangeServices
Pre-PackagedSoftwareDevelopment
SoftwareInstallation,IntegrationandMaintenance
SoftwareMaintenanceandSupport
SystemsAnalysisandDesign
SystemEngineering
SystemIntegration
Telecommunications
ValueAddedReseller
WebHosting
WebDesign
Other
TECH.APP.001 (1216) Page: 4 of 13
MISCELLANEOUS PROFESSIONAL LIABILITY (please complete if Miscellaneous Professional Liability coverage is beingrequested)
15.MiscellaneousProfessionalLiabilityCoverage:
a.Pleaseprovideacomprehensivedescriptionofprofessionalservicesperformedforothersforafee.
CONTRACTS
16.ContractualContentandProcedures:
a.Doyourequireawrittencontractoragreementforyourservicesorproductswithallcustomers
Ifyes,whatpercentageoftimearetheyused? %
YesNo
b. Areallcontractsreviewedbylegalcounselorathirdpartylawfirm?
Ifno,doeslegalcounselreviewanycontractsthataremodifiedordeviatedfromstandard?
YesNo
YesNo
c. Dosuchcontractsoragreementscontain(checkallthatapply):
Statementofworkandspecifications?
Limitationofliabilities?
Limitationofliabilityforconsequentialdamages?
Guaranteesofwarranties?
Holdharmlessorindemnityagreementsinuringtoyourbenefit?
Holdharmlessorindemnityagreementsinuringtoyourclient’sbenefit?
Provisionforliquidateddamages?
Acceptanceofconsequentialdamages?
Provisionfortheownershipofintellectualproperty?
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
17.TopFiveCustomerContracts:Providethefollowinginformationregardingyourfivelargestexistingcontracts.
Client SizeofContract LengthofContract Natureofproductsorservices
1.
2.
3.
4.
5
a.Foryourlargestfivecontracts,aretheyallwrittenonyourstandardcustomercontract?
Ifno,pleasedescribetheprocessforapprovalofcontracts,deviationsandmodifications.
YesNo
TECH.APP.001 (1216) Page: 5 of 13
18.VendorContracts:
a.Doyourequirewrittencontractsoragreementswithallvendors?
b.Isthecontractingprocessstandardizedorformalized?
c.Areallcontractsreviewedbyyourlegaldepartmentorathirdpartylawfirm?
YesNo
YesNo
YesNo
19.QualityAssurance:
a.DoyourproductsorservicescomplywithanywidelyacceptedindustrystandardssuchasISO/ANSI/ULorothers?(Checkallthequalitycontrolproceduresthatapply)
b.Doyouhaveaformalwrittensystemorsoftwaredevelopmentmethodologyinplace?
Ifyes,doyouobtainyourcustomerswrittenacceptanceofsystemsorsoftwarepriortoproductionorimplementation?
c.Docontractsorstatementsofworkincludedperformancemilestoneswhichareacknowledgesandacceptedwithsignoffsbybothyouandyourcustomer?
d.Arefinalacceptancelettersorsignoffsrequiredfromeachcustomer?
e.Doyouhaveaformalcomplaintresolutionpolicyforhandlingcustomercomplaintsorrequestsforcorrectionsincludingtheescalationprocess?
f.Doyouhaveacustomernotificationplanintheeventaproductorserviceisdiscontinued?
g.Describeanyproductsorservicesthathavebeendiscontinuedorrecalledwithinthepastyear,theproceduresusedfortherecallandanysupportorotherremedyforsuchdiscontinuedproductsorservices.
h.Doyouhaveprocedurestosafeguardagainstcopyrightinfringementarisingoutofsystemsand/orsoftwaredesigned,developedormodifiedbyyou?
i.Doyouuseindependentcontractorsand/orsubcontractors?
Ifyes,thenanswerthefollowing:
Doyouusealwaysuseawrittencontractuponengagementofindependentcontractors?
Doyourequireindependentcontractstocarryprofessionalliabilityinsurance?
Doallcontractswithindependentcontractorsclearlyidentifyworkproductas“workforhire”,orincludeotherprovisionsfortheownershipofintellectualproperty?
Alphatesting Milestonemanagement
Betatesting Totalqualitymanagement
Prototypedevelopment Formalcustomeracceptanceprocedures
Statisticalprocesscontrol Other:
Vendorcertificationprocess
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo YesNo
YesNo YesNo
YesNo
YesNo
YesNo
TECH.APP.001 (1216) Page: 6 of 13
INTERNETMEDIA(pleasecompleteifInternetMediacoverageisbeingrequested)
20.InternetMediaandIntellectualProperty:
a. Doyoudevelopcontentotherthanmarketingmaterials,brochuresorwebsitecontent? YesNo
Ifyesprovidethepercentageofthefollowing:
Originalcontentcreatedbyapplicant: %
Originalcontentcreatedbythirdpartiesforapplicant: %
Contentfurnishedbythirdpartiestoapplicantviaalicensingagreement: %
b. Doyoumaintainpoliciesorprocedurestoscreenallformsofcontentforpotentialinfringementofthirdpartyintellectualpropertyrights?
YesNo
c. c.Doyoumaintainpoliciesorprocedurestoscreenallformsofcontentforelementsthatmayleadtopersonalinjuryclaimsincludingbutnotlimitedtolibel,slanderanddefamation?
YesNo
d. Doyousell,distributeordevelopsoftwarethatissubjecttoanopensourcelicense? YesNo
e. Doyouhavewrittenpoliciesorproceduresinplacetoaudittheuseofsoftwarelicenses? YesNo
f.Doyourequirethirdpartieswhoprovideyouwithcopyrightablematerialto:
Holdyouharmlessforintellectualpropertyinfringementclaims YesNo
Indemnifyyouforintellectualpropertyclaims YesNo
Warrantthattheirworkdoesnotviolateanotherparty’sintellectualpropertyrights YesNo
Assignorlicensetheirintellectualpropertyrightstoyou YesNo
g.Doanyofyourwebsiteslink,deeplinkorframetootherwebsitesownedbyathirdparty? YesNo
h.Doyoumaintainacommercialgeneralliabilitypolicywithadvertisingandpersonalinjurycoverage?
YesNo
i.Inthepastthreeyearshaveyoureceivednoticeofinfringementonanythirdparty’sintellectualpropertyrights?
Ifyes,pleaseprovideanattachmentwithadescriptionofsuchinfringement.
YesNo
f.
TECH.APP.001 (1216) Page: 7 of 13
NETWORK SECURITY AND PRIVACY (please complete questions 22 through 26 if Network Security and Privacy Liabilitycoverageisbeingrequested)
21.EnterpriseSecurityandPrivacy–People:
a. DoyouhaveaChiefInformationSecurityOfficer? YesNo
b. DoyouhaveaChiefPrivacyOfficer? YesNo
c. Doyoueducateusersoninformationsecurityandprivacy? YesNo
d. DoyouuseThirdPartyServicesProviders?
Ifyes,checkallthatapplyandidentifythethirdpartyvendor(s):
ManagedSecurityServices
PhysicalSecurityServices
Collocationservices
Internetserviceprovider
ApplicationServiceProvider
Websitehosting
DisasterRecovery
Vulnerabilityassessmentandpenetrationtesting
Informationsecurityriskassessments
Dataarchivingandrestoration
Datadestruction
Creditcardprocessing
Other(e.g.Humanresourceandbenefits)
YesNo
e. Doyououtsourceanybusinessfunction(s)thatwouldallowthirdpartiesaccesstopersonalorcorporateinformationinyourcare,custodyorcontrol?
Ifyes,doyourcontractsrequirethatsuchthirdpartiesmaintainnetworksecurityinsuranceorthattheydefendandindemnifyyouintheeventsuchinformationiscompromisedasaresultoftheirnegligence?
YesNo
YesNo
f. Doyouholdyourvendorstothesamesecurityandprivacystandardasyourinternalcontrols?
YesNo
TECH.APP.001 (1216) Page: 8 of 13
22.EnterpriseSecurityandPrivacy–Processes:
a.Doyoucategorizeaneventtodeterminetheseverityofanincidentandhowyoushouldrespond?
YesNo
b.Doyoudefinethreatassessmentsfromlow,mediumorhighseveritylevels? YesNo
c. Doyouactivelymaintainandreviewsecuritylogsforirregularities,intrusionsorviolations?Ifyes,howoftenarelogschecked,andwhomaintainsthisresponsibility?
YesNo
d. Doyoureportyourincidenthandlingprogramresultstoseniormanagement,theboardofdirectorsorauditors?
YesNo
e. Aresystembackupandrecoveryproceduresdocumentedandtestedforallmissioncriticalsystems?
YesNo
f. Arethesystemsbackeduponadailyormoreregularbasis? YesNo
23.EnterpriseSecurityandPrivacy–Technology:
a. Doyouutilizefirewallandroutertechnology? YesNo
b. Doyouemployintrusiondetectionorpreventionsystems? YesNo
c. Doyouuseanti-virussoftware? YesNo
d. Doyouusepasswordstoauthenticateusers?
Ifyes,whatisthepasswordlength? 4 5 6 7 8 9
Dopasswordsutilize?(checkallthatapply):
charactersinlowercase digits
charactersinuppercase commonpunctuation
YesNo
e. Doyouusecommercialgradetechnologytoencryptallnon-publicpersonalandconfidentialcorporateinformationtransmittedwithinyourcompanyortootherpublicnetworks?
YesNo
f. Dousecommercialgradetechnologytoencryptallnon-publicpersonalandconfidentialcorporateinformationatrestwithinyournetwork?
YesNo
g. Doyouusecommercialgradetechnologytoencryptallnon-publicpersonalandconfidentialcorporateinformationthatisphysicallytransmittedbytapeorothermediumbetweenyourcompanyandthirdparties,includingdatastoragecompanies?
YesNo
h. Doyouusecommercialgradetechnologytoencryptharddrivesforallmobilecomputerequipmentincludinglaptopsandhandhelddevices?
YesNo
i. ArewirelesstransmissionsprotectedusingWPA/WPA2,IPSECorSSL? YesNo
j. Arecomputersystems,applicationsandserversthatcollectnon-publicpersonalinformationandconfidentialcorporateinformationsegregatedfromtherestofthenetwork?
YesNo
k. Hasanindependentnetworksecurityassessmentorauditbeenconductedwithinthepast12months?
Ifyes,whoperformedtheauditandwhenwastheauditcompleted?
YesNo
l. Haveallvulnerabilitiesidentifiedintheauditbeenremediated? YesNo
m. Haveinternalorexternalvulnerabilityscansbeenconductedwithinthepast12months?
Ifyes,whoperformedthescansandwhenwasthescancompleted?
YesNo
n. Havethevulnerabilitiesidentifiedinthescanbeenremediated? YesNo
o. Doproceduresexisttomonitornewvulnerabilitieswithinyourcomputersystemandapplythelatestsecuritypatcheswithinonemonth?
YesNo
TECH.APP.001 (1216) Page: 9 of 13
24.PoliciesandProcedures:
a. Hasmanagement,theboardofdirectorsoradesignatedcommitteeapprovedawritteninformationsecurityprogramandoverseetheimplementationandmaintenance?
YesNo
b. DoesaBoardapprovedenterprisewidepolicycoveringnon-publicpersonalinformationandconfidentialcorporateinformationexistwithinyourorganization?
Ifno,pleasedescribe:
Ifyes,doesthepolicyincludeenforceableprovisionsfornon-compliancebyemployees,independentcontractorsandthirdpartyserviceproviders?
YesNo
YesNo
c. Doyoumaintainawritteninformationsecuritypolicy? YesNo
d. Doyoumaintainawrittenprivacypolicy? YesNo
e. e.Doyoumaintainawrittendatabreachresponseplan?Ifso,doestheplaninclude
f. (checkallthatapply):
formalassignmenttoaseniormanagerformanagingthebreachresponse?
alegalreviewtoexaminetheapplicant’sresponsibilitytonotify?
identificationofanexternalforensicinvestigativeresource?
anidentityrestorationserviceorcreditmonitoringprovider?
acommunicationplantonotifyaffectedindividuals?
YesNo
f.Doyouhaveanetworksecurityincidentresponseplan?
YesNo
g.Doyoumaintainawrittendisasterrecovery/businesscontinuitypolicy?
Ifyes,arethebusinesscontinuityanddisasterrecoveryplanstestedatleastannually?
YesNo
YesNo
h.Doyoumaintainawrittenrecordsretentionanddestructionpolicy? YesNo
i.Doyoufollowestablishedproceduresforcarryingoutandconfirmingthedestructionofsensitiveinformationinelectronicandpaperformatpriortorecyclingorphysicaldisposal?
YesNo
j. Doyoumaintainawrittene-mailpolicy? YesNo
k. DoyoumaintainawrittenacceptableInternetusagepolicy? YesNo
l. Doyoumaintainawrittenpolicyfordataclassificationpolicythatranksassetsaccordingtosensitivityandhowmuchprotectionisrequired?
YesNo
m. Doyouhaveaphysicalsecuritypolicydesignedtoprohibitandtrackunauthorizedaccesstoyournetwork,computersystemsanddatacenters(ifapplicable)?
YesNo
n. Doyouhavephysicalaccesscontrolstoyourbuildingandofficescontrolledorlimited(e.g.keycards,biometrics,etc,)?
YesNo
o. Arebackgroundchecksperformedonemployeeswithaccesstonon-publicpersonalinformationandconfidentialcorporateinformation?
YesNo
p. Isaformalprocessinplacetoensurethatnetworkprivilegesandphysicalaccesstothebuildingarerevokedinatimelymannerfollowinganemployee’sterminationorresignation?
YesNo
q. Doyouhaveproceduresforcarryingoutandconfirmingthedestructionofdataresidingyourcomputersystemordevicespriortotheirrecycling,refurbishing,resale,orphysicaldisposal?
YesNo
TECH.APP.001 (1216) Page: 10 of 13
25.RecordNumberandType:
a. Doyoustore,processand/ortransmitinanyformat? YesNo
Ifyes,checkallthatapplyandapproximatenumberofrecords:
FinancialAccountNumbers CreditCardInformation
SocialSecurityNumbers SecuritiesInformation
DriversLicenseNumbers TradeSecrets
HealthcareInformation IntellectualProperty
26.RegulatoryCompliance:
a.Areyousubjecttoanyofthefollowingregulations?
Ifyes,checkallthatapply:
Gramm-LeachBlileyActof1999
HealthInsurancePortabilityandAccountabilityActof1996andHITECH
IdentityTheftRedFlagsundertheFairandAccurateCreditTransactionsActof2003
PaymentCardIndustry(PCI)DataSecurityStandard
Ifyes,pleaseindicatelevelrequirement:1 2 3 4
YesNo
b.Areyoucurrentlycompliantwiththefollowingregulations?(checkallthatapply):
Gramm-LeachBlileyActof1999
HealthInsurancePortabilityandAccountabilityActof1996
HealthInformationTechnologyforEconomicandClinicalHealthActof2009
IdentityTheftRedFlagsundertheFairandAccurateCreditTransactionsActof2003
PaymentCardIndustry(PCI)DataSecuritySafeguard
Ifyes,whenwasthedateofthelastregulatoryorPCIindependentthirdpartyassessment?
YesNo
YesNo
YesNo
YesNo
YesNo
TECH.APP.001 (1216) Page: 11 of 13
27.HISTORICALINFORMATION:(ForallApplicants)
a. HasyourcompanyeverbeendeclinedforTechnologyErrorsandOmissions,Privacy,NetworkSecurity,InternetMediaLiabilityorMiscellaneousProfessionalLiabilityinsurance,orhadanexistingpolicycancelled?
YesNo
b. Hasyourcompanyeverexperiencedanetworkbreach,tampering,virusormaliciouscodeattack,lossofdata,hackingincident,datatheftorsimilar?
YesNo
c. IsyourChiefExecutiveOfficer,ChiefOperatingOfficer,ChiefFinancialOfficer,ChiefInformationOfficer,ChiefSecurityOfficer,ChiefPrivacyOfficer,President,GeneralCounsel,RiskManager,principal,partner,directororofficerawareoforarethereanycircumstancesthatcouldgiverisetoaclaimthatwouldbecoveredbythisPolicy?
YesNo
d. Inthelastfiveyears,hasyourcompanyexperiencedanyclaims,suits,proceedingsorareyouawareofanycircumstancesthatcouldgiverisetoaclaimthatwouldbecoveredbythisPolicy? YesNo
e. Inthelastthreeyears,hasanyoneallegedthattheirpersonalinformationwascompromisedorhaveyounotifiedanythirdpartiesthatnon-publicpersonalinformationwascompromised?
YesNo
f. Duringthelastthreeyears,hasyourcompanyreceivedacomplaintconcerningthecontentofyourwebsiteorotheronlineservicesrelatedtointellectualpropertyinfringement,contentoffenses,oradvertisingoffenses?
YesNo
g. Duringthelastthreeyears,hasyourcompanybeenthesubjectofaninvestigationoractionbyanyregulatoryoradministrativeagencyforviolationsarisingoutofyouradvertising,datasecurityorprofessionalservices?
YesNo
h. Withinthelastthreeyears,hasacustomerclaimedthattheyhadafinanciallossasaresultofanerrororomissiononyourpart?
YesNo
i. Hasyourcompany,oranyofyourpredecessorsinbusiness,subsidiariesoraffiliates,oranyoftheprincipals,directors,officers,partners,professionalemployeesorindependentcontractorseverbeenthesubjectofadisciplinaryactionasaresultofprofessionalactivities?
YesNo
IfaYesanswerhasbeengiventoanyofthequestionsinthissection,pleaseprovidecompletedetailswhichshouldincludebutnotbelimitedtothefollowing:
• Afulldescriptionincludingdamagesalleged• Datetheinsurancecarrierwasputonnotice• Currentstatus
• Amountsofreserves,legalexpensepaid,andsettlementsorjudgments• Lossruns• Stepsimplementedtopreventsimilarclaims
TheundersignedApplicantrepresentsthatthestatementssetforthinthisapplicationanditsattachmentsandothermaterialssubmittedtotheInsureraretrueandcorrect.SigningofthisapplicationdoesnotbindtheApplicantortheInsurer.IntheeventthereisanymaterialchangeintheanswerstothequestionshereinpriortotheissuancedateofthePolicythatwouldrenderthisapplicationforminaccurateorincomplete,theApplicantwillnotifytheInsurerinwriting,and,ifnecessary,anyoutstandingquotationmaybemodifiedorwithdrawn.
TECH.APP.001 (1216) Page: 12 of 13
FRAUDWARNINGSNOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY ORANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSEINFORMATION,ORCONCEALSFORTHEPURPOSEOFMISLEADING, INFORMATIONCONCERNINGANYFACTMATERIALTHERETO,COMMITSAFRAUDULENTINSURANCEACT,WHICHISACRIMEANDSUBJECTSTHEPERSONTOCRIMINALPENALTIES.NOTICE TO ALABAMA APPLICANTS: ANY PERSON WHOKNOWINGLY PRESENTSA FALSEOR FRAUDULENTCLAIM FORPAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLYPRESENTS FALSE INFORMATION IN AN APPLICATION FORINSURANCE ISGUILTYOFA CRIMEANDMAYBE SUBJECT TORESTITUTION, FINES, OR CONFINEMENT IN PRISON OR ANYCOMBINATIONTHEREOF.NOTICE TO ARKANSAS, LOUISIANA, MARYLAND, NEWMEXICO, RHODE ISLAND AND WEST VIRGINIA APPLICANTS:ANY PERSON WHO KNOWINGLY PRESENTS A FALSE ORFRAUDULENTCLAIMFORPAYMENTOFALOSSORBENEFIT,ORKNOWINGLY PRESENTS FALSE INFORMATION IN ANAPPLICATIONFORINSURANCEISGUILTYOFACRIMEANDMAYBESUBJECTTOFINESANDCONFINEMENTINPRISON.NOTICE TO COLORADO APPLICANTS: IT IS UNLAWFUL TOKNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADINGFACTS OR INFORMATION TO AN INSURANCE COMPANY FORTHEPURPOSEOFDEFRAUDINGORATTEMPTINGTODEFRAUDTHE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANYINSURANCE COMPANY OR AGENT OF AN INSURANCECOMPANYWHO KNOWINGLY PROVIDES FALSE, INCOMPLETEORMISLEADINGFACTSORINFORMATIONTOAPOLICYHOLDEROR CLAIMANT FOR THE PURPOSE OF DEFRAUDING ORATTEMPTINGTODEFRAUDTHEPOLICYHOLDERORCLAIMANTWITHREGARDTOASETTLEMENTORAWARDPAYABLEFROMINSURANCE PROCEEDS SHALL BE REPORTED TO THECOLORADO DIVISION OF INSURANCE WITHIN THEDEPARTMENTOFREGULATORYAGENCIES.NOTICE TODISTRICTOF COLUMBIAAPPLICANTS:WARNING:IT IS A CRIME TO PROVIDE FALSE OR MISLEADINGINFORMATION TO AN INSURER FOR THE PURPOSE OFDEFRAUDING THE INSURER OR ANY OTHER PERSON,PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. INADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IFFALSE INFORMATIONMATERIALLYRELATEDTOACLAIMWASPROVIDEDBYTHEAPPLICANT.NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHOKNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, ORDECEIVEANY INSURER FILESA STATEMENTOF CLAIMORANAPPLICATION CONTAINING ANY FALSE, INCOMPLETE ORMISLEADING INFORMATION IS GUILTY OF A FELONY OF THETHIRDDEGREE.
NOTICE TO KENTUCKY APPLICANTS: ANY PERSON WHOKNOWINGLY ANDWITH INTENT TO DEFRAUD ANY INSURANCECOMPANY OR ANOTHER PERSON, FILES AN APPLICATION FORINSURANCE CONTAINING ANY MATERIALLY FALSEINFORMATION, OR CONCEALS FOR THE PURPOSE OFMISLEADING,INFORMATIONCONCERNINGANYFACT,MATERIALTHERETO,COMMITSAFRAUDULENTINSURANCEACT,WHICHISACRIME.NOTICE TO MAINE, TENNESSEE, VIRGINIA ANDWASHINGTONAPPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE,INCOMPLETEORMISLEADINGINFORMATIONTOANINSURANCECOMPANY FOR THE PURPOSEOFDEFRAUDING THE COMPANY.PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIALOFINSURANCEBENEFITS.NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHOINCLUDES ANY FALSE ANDMISLEADING INFORMATION ON ANAPPLICATION FOR AN INSURANCE POLICY IS SUBJECT TOCRIMINALANDCIVILPENALTIES.NOTICETOOHIOAPPLICANTS:ANYPERSONWHO,WITHINTENTTO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING AFRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION ORFILESACLAIMCONTAININGAFALSEORDECEPTIVESTATEMENTISGUILTYOFINSURANCEFRAUDNOTICE TO OREGON APPLICANTS: ANY PERSON WHOKNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, ORDECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR ANAPPLICATION CONTAINING ANY MATERIALLY FALSE,INCOMPLETE,ORMISLEADINGINFORMATIONMAYBEGUILTYOFINSURANCEFRAUD.NOTICETOOKLAHOMAAPPLICANTS -WARNING:ANYPERSONWHOKNOWINGLYANDWITH INTENTTO INJURE,DEFRAUDORDECEIVEANY INSURER,MAKESANY CLAIM FOR THE PROCEEDSOFANINSURANCEPOLICYCONTAININGANYFALSE,INCOMPLETEORMISLEADINGINFORMATIONISGUILTYOFAFELONY.NOTICE TO PENNSYLVANIA APPLICANTS: ANY PERSON WHOKNOWINGLY ANDWITH INTENT TO DEFRAUD ANY INSURANCECOMPANY OR ANOTHER PERSON, FILES AN APPLICATION FORINSURANCE OR STATEMENT OF CLAIM CONTAINING ANYMATERIALLY FALSE INFORMATION, OR CONCEALS FOR THEPURPOSE OF MISLEADING, INFORMATION CONCERNING ANYFACT, MATERIAL THERETO, COMMITS A FRAUDULENTINSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCHPERSONTOCRIMINALPROSECUTIONANDCIVILPENALTIES.
TECH.APP.001 (1216) Page: 13 of 13
NOTICE TONEWYORKAPPLICANTS:ANYPERSONWHOKNOWINGLYANDWITH INTENT TODEFRAUDANY INSURANCECOMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSEINFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIALTHERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVILPENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUEOF THE CLAIM FOR EACH SUCHVIOLATION.
Signature:
PrintName:
Title: Date:
Theapplicationmustbesignedbeanddatedbyanauthorizedofficer,partnerorprincipaloftheApplicant.
