Application – Cyber Security Liability

Philadelphia Insurance Companies

  • CENTERPOINT INSURANCE GROUP
    INDIVIDUAL APPLICANTS - COLORADO DEPARTMENT OF HUMAN SERVICES

    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 bold. Throughout this Application the words "you" and "your" refer to the Named Insured shown in the Declarations, and any other person or organization qualifying as a Named Insured under the proposed policy.
  • Section I - General Information

  • Section II - Loss Experience

  • Section III - Risk Controls

  • 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.
  • Date Format: MM slash DD slash YYYY
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