Fillable CYBER LIABILITY AND PRIVACY CRISIS MANAGEMENT EXPENSE APPLICATION (Risk Placement Services, Inc.)

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CYBER LIABILITY AND PRIVACY CRISIS MANAGEMENT EXPENSE APPLICATION (Risk Placement Services, Inc.)

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CYBER LIABILITY AND PRIVACY CRISIS MANAGEMENT EXPENSE
APPLICATION
THIS APPLICATION IS FOR A FIRST DISCOVERY POLICY. COVERAGE IS FOR EVENTS
FIRST DISCOVERED DURING THE "POLICY PERIOD" OR ANY APPLICABLE EXTENDED
REPORTING PERIOD, AND REPORTED TO US IN ACCORDANCE WITH THE TERMS OF THE
POLICY.
A. GENERAL INFORMATION SECTION
1. Named Organization (Applicant):
_____________________________________________________________________________
2. Mailing address:
_____________________________________________________________________________
i. (street) (city) (county) (state) (zip code)
3. Telephone number: (___)_________________ Fax number: (___)___________________
4. E-mail address: ________________________ Web site address: _______________________
5. Contact name: _____________________________________
6. Is your organization organized under the not-for-profit status of the Internal Revenue Code?
□ Yes □ No
7. Type of Entity: (Individual, Partnership, Joint Venture, Corporation, Other)
__________________________ State of Incorporation (if applicable)________________
8. Description of operations:_____________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. Does your organization store personal identifiable customer information on your computer
network?
Yes No If yes, what type of information is kept(i.e. Credit Card #, Social Security #,
medical data, etc.
): ____________________________________________________________________
_
___________________________________________________________________________________
B. EXPOSURE INFORMATION SECTION
Cybe
r Liabil
ity protects you when claims are made against you for monetary damages arising out of an
electronic information security event:
Privacy Crisis Management Expense reimburses for expenses you incur as a result of a privacy crisis
management event first discovered during the policy period. This first party coverage is intended to
provide professional expertise in the identification and mitigation of a privacy breach while satisfying
Federal and State statutory requirements.
Event Limit General Aggregate Limit
$50,000 Same as Event Limit
$100,000 Two times Event Limit (2X)
$250,000 Three times Event Limit (3X)
Other:___________
CY 00 02 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc.,
with its permission.
Page 2 of 5
1. Do you use anti-virus software on all desktops, laptops, portable devices, and network servers?
Yes No
2. Is firewall management software installed on your computer network?
Yes No
3. Do you have computer network and information security policies which must be followed by a
ll
employees, v
olunteers and third party service providers?
Yes No
4. Is there an individual within your organization designated as responsible for compliance with
HIPAA and HITECH Act (Health Information Technology for Economic and Clinical Health Act)?
Yes No
5. Is your security policy communicated to all employees and volunteers who have access to pati
ent
inform
at
ion?
Yes No
6
. Are employees allowed to store/download personally identifiable information or protected
health information on laptops or external storage devices? Yes No
7. Does your computer network and/or information security policy include a response plan in the
event of a data breach that includes notification to appropriate stakeholders? Yes No
8. Do you require written contracts with third party service providers who have access to your data
to include a hold harmless clause, and your organization is named as an Additional Insured on
their policy? Yes No
9. Do you require written contracts to enforce your computer network and information security
policy with third party service providers? Yes No
10. During the past three years, have you ever sustained any losses arising out of unauthorized
disclosure of confidential corporate information or personal identifiable information? Yes No
If “yes”, please explain.
____________________________________________________________________________________________
____________________________________________________________________________________________
11. During the past three years, have you ever been the subject of an investigation by any regulatory
or administrative agency for privacy-related violations? Yes No
If “yes”, please explain.
____________________________________________________________________________________________
____________________________________________________________________________________________
FRAUD STATEMENT
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD STATEMENT TO ALABAMA APPLICANTS
CY 00 02 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc.,
with its permission.
Page 3 of 5
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to restitution fines or confinement in prison, or any combination thereof.
FRAUD STATEMENT TO ARKANSAS APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD STATEMENT TO COLORADO APPLICANTS
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 settlement or award payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of regulatory agencies.
FRAUD STATEMENT TO DISTRICT OF COLUMBIA APPLICANTS
WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefits if false information materially related to a claim was provided by the
applicant.
FRAUD STATEMENT TO FLORIDA APPLICANTS
Any person who knowingly, and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete or misleading information is guilty of a felony of
the third degree.
FRAUD STATEMENT TO KENTUCKY APPLICANTS
Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance containing any materially false information, or conceals, for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which
is a crime.
FRAUD STATEMENT TO LOUISIANA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD STATEMENT TO MAINE APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of
insurance benefits.
FRAUD STATEMENT TO MARYLAND APPLICANTS
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or
benefit or who knowingly and willfully presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO NEW JERSEY APPLICANTS
CY 00 02 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc.,
with its permission.
Page 4 of 5
Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
FRAUD STATEMENT TO NEW MEXICO APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to civil fines and criminal penalties.
FRAUD STATEMENT TO NEW YORK 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 conceals for
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand
dollars and the stated value of the claim for each such violation.
FRAUD STATEMENT TO OHIO APPLICANTS
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false or deceptive statement is guilty of insurance
fraud.
FRAUD STATEMENT TO OKLAHOMA APPLICANTS
WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading
information is guilty of a felony.
FRAUD STATEMENT TO OREGON APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents materially false information in an application for insurance may be guilty of a crime
and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO PENNSYLVANIA 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 conceals for
the purpose of misleading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subjects such person to criminal and civil penalties.
FRAUD STATEMENT TO RHODE ISLAND APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance, including failing to disclose whether
the applicant or applicants have been convicted of any degree of the crime of arson, is guilty of a crime
and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO TENNESSEE APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance
benefits.
FRAUD STATEMENT TO VERMONT 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 conceals for
CY 00 02 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc.,
with its permission.
Page 5 of 5
the purpose of misleading, information concerning any fact material thereto, commits a fraudulent
insurance act, which may be a crime and subjects such person to criminal and civil penalties.
FRAUD STATEMENT TO VIRGINIA APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance
benefits.
FRAUD STATEMENT TO WASHINGTON APPLICANTS
It is a crime to knowingly provide false, incomplete or misleading information to an insurance company
for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance
benefits.
FRAUD STATEMENT TO WEST VIRGINIA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
______________________________________________ _______/_______/_______
Signature of Applicant Date
______________________________________________
Name and Title
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CYBER LIABILITY AND PRIVACY CRISIS MANAGEMENT EXPENSE APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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