Fillable CYBER SECURITY LIABILITY APPLICATION SUPPLEMENTAL CLAIM INFORMATION Name (Philadelphia Insurance Companies)

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CYBER SECURITY LIABILITY APPLICATION SUPPLEMENTAL CLAIM INFORMATION Name (Philadelphia Insurance Companies)

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PI-CYB-015 NY (09/11)
Page 1 of 3
1. Full name of the Applicant Firm:
2. Full name of the firm which reported the claim (if different from above):
3. Full name of the claimant:
4. Indicate whet
her: Claim/Suit Incident/Potential Claim
5. Date / Period of alleged error:
6. Date the claim was reported to the insurance carrier:
7. Other parties against which this claim is made:
8. This claim is:
Open Closed
9.
If CLOSED, indicate the date closed:
10. Please complete the following:
If claim is still open:
a. Claimants settlement demand: $
b. Defendant’s offer for settlement: $
c. Insurance company’s loss reserve: $
d. Deductible: $
e. Total loss and expenses paid to date: $
If claim is closed:
a. Loss paid in excess of deductible: $
b. Expenses paid in excess of deductible: $
c. Deductible: $
d. Settlement reached via:
Court judgment Formal mediation/Arbitration proceeding Out of court settlement
Note: If information is not available, please provide a copy of the suit papers.
11. Name of Insurance company:
12. Claim number:
CYBER SECURITY LIABILITY APPLICATION
SUPPLEMENTAL CLAIM INFORMATION
Name of Insurance Company to which Application is made (herein called the “Insurer”)
THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY
THE LIMITS OF LIABILITY AVAILABLE TO PAY CLAIMS OR SUITS ANDTHE DEDUCTIBLE
MAY BE REDUCED BY AMOUNTS INCURRED AS DEFENSE COSTS UNDER COVERAGES E., F., AND G.
Submit one form for each claim or incident. If space is insufficient to answer any question completely,
please use the Additional Information page attached to this application.
Clear Application
Print Application
PI-CYB-015 NY (09/11)
Page 2 of 3
13. Description of claim / incident:
a. Provide a full description of the engagement, the events leading up to the claim, allegation asserted,
against your firm and the current status of the matter. Please indicate if the claimant was your client.
If no, fully explain claimant’s relationship to client:
b. Was an engagement letter used? Yes No
c. What action has your firm taken to prevent a recurrence of such a claim in the
future?
d. Did this incident or claim follow or result from an action to collect fees? Yes No
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companies Cyber Security application and is subject to the same conditions as stated on the application.
FRAUD NOTICE STATEMENT
NOTICE TO 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.”
Name (Please Print/Type) Title
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO, OR
EXECUTIVE DIRECTOR
)
____________________________________________________
Signature Date
The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons.
Clear Application
Print Application
PI-CYB-015 NY (09/11)
Page 3 of 3
ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please
identify the question number to which you are referring.
__________________________________________
Signature
Date
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CYBER SECURITY LIABILITY APPLICATION SUPPLEMENTAL CLAIM INFORMATION Name (Philadelphia Insurance Companies)

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Completed 29 July 2020

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