COVERAGES E., F., AND G. ARE CLAMIS MADE AND REPORTED COVERAGES.
CLAIM EXPENSES UNDER COVERAGES E., F., AND G. ARE INCLUDED WITHIN THE AVAILABLE LIMIT OF INSURANCE. ANY CLAIM EXPENSES PAID UNDER THIS COVERAGE FORM WILL REDUCE THE AVAILABLE LIMITS OF INSURANCE AND MAY EXHAUST THEM COMPLETELY. PLEASE READ THE ENTIRE POLICY CAREFULLY.
Certain terms have specific meaning as defined in the policy form and noted in
. Throughout this Application the words "you" and "your" refer to the
shown in the Declarations, and any other person or organization qualifying as a
under the proposed policy.
Section I - General Information Name of Applicant * Address * City * State * Zip * Phone * Website
Nature of Operations * Annual Revenue ($USD) * Number of Clients * Section II - Loss Experience During the past three (3) years have you sustained any loses due to unauthorized access, unauthorized use, virus, denial of service attack, data breach, data theft, fraud, electronic vandalism, sabotage or other similar electronic security events? * During the past three (3) years, has anyone alleged that you were responsible for damage to their comuputer system(s) arising out of the operation of your computer system(s)? * During the past three (3) years, has anyone made a demand, claim, complaint, or filed a lawsuit against you alleging invasion of, or interference with rights of privacy, or the inappropriate disclosure of personally identifiable information (PII)? * During the past three (3) years, have you been the subject of an investigation or action by any regulatory or administrative agency for privacy-related violations? * Section III - Risk Controls Do you have a firewall? * Do you have a virus protection program in place? * Do you have a designated individual responsible for information security? * Do you have a written privacy or security policy? * Do you control access to your computer systems? * Do you have a program or procedure in place to test your security/privacy controls? * Do you encrypt confidential client information stored on laptops, mobile devices, or other storage media?? * FRAUD STATEMENTS AND SIGNATURE SECTIONS The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company* in quoting and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the company of such changes and the Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers to Tokio Marine Specialty Insurance Company
FRAUD NOTICE STATEMENTS
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. Name (Print) * Title * Date *
Date Format: MM slash DD slash YYYY