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INTEGRATED TECHNOLOGY APPLICATION (Philadelphia Insurance Companies)

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INTEGRATED TECHNOLOGY APPLICATION
SUBMISSION REQUIREMENTS
•
Copies of your current contracts or license agreements
•
Current audited financial statement
•
Five (5) years of currently valued loss runs
GENERAL INFORMATION (to be completed by all Applicants)
1.
Name of Applicant(as it should appear on policy):
2.
Street Address:
3.
City, State, Zip Code:
4.
Website Address:
5.
Business Type:
Corporation
Partnership
Joint Venture
LLC
6.
Public
Private
Not-for-Profit
7.
Year Established:
Number of Employees:
1. Select each coverage and indicate the Limit of Liability and Deductible for which you are applying.
Coverage Limit of Liability Deductible
Technology Errors & Omissions $ $
Media Liability $ $
Network Security $ $
Privacy Regulation Proceeding Sublimit $ $
Privacy Event Expenses Sublimit $ $
Extortion Sublimit $ $
2. What is the proposed effective date (mm/dd/yyyy) of coverage:
3. Do you currently have a policy in force providing any of the above coverages? Yes No
Coverage Technology E&O Media Liability
Network Security/
Privacy Injury
Carrier
Policy Period
Limit of Liability $ $ $
Retention $ $ $
Claims Made or Occurrence
Retroactive Date
Premium $ $ $
1. Indicate on what date your fiscal year ends:
2. Indicate your gross annual revenue for the following twelve (12) month fiscal time periods.
Revenue Split Prior Fiscal Period Current Fiscal Period Next Fiscal Period
Domestic $ $ $
Foreign $ $ $
Total $ $ $
SECTION I - COVERAGES (to be completed by all Applicants)
.
SECTION II - REVENUE (to be completed by all Applicants)
8. Risk Management’s Phone: Risk Management Contact:
Risk Management Email:
Integrated Technology
Page 1 of 7
© 2018 Philadelphia Consolidated Holding Corp.
03/2018
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1.
Description of operations:
Estimate the total percentage of revenue for the following services and work.
Technology – Software & Services % Technology – Hardware & Equipment %
Application Service Provider % Computer System Manufacturing %
Application Mobile Device Development % Computer Peripherals Manufacturing %
Cloud Computing – Private % Electronic Component Manufacturing %
Cloud Computing – Public % Instrument Manufacturing %
Custom Software Development % Office Electronics Manufacturer (other than %
computers)
Data Processing & Outsourced Services % Recycling/Destruction of Hardware %
Domain Name Registration % Telecommunications Equipment Manufacturing %
E-Mail Services %
Other (describe):
%
Internet Service Provider %
IT Consulting %
IT Staff Augmentation %
Distribution %
Managed IT Services % Computer Equipment & Software Distribution %
Network Security Software and Services % Electronic Component Distribution %
Outsourcing % Instrument Distribution %
Pre-Packaged Software Development/
Sales
%
Other (describe):
%
System Design and Integration %
Telecommunication Services %
Technical Support/Repair & Maintenance % Local & Long Distance Service Providers %
Training & Education % Telecommunications Consulting %
Value-Added Reseller Software % Telecommunications Installation %
Web Portal % Telephone Companies %
Website Hosting % Video Conferencing Services %
Website Construction and Design % Voice Over Internet Protocol Services (VOIP) %
Wholesale Software Distribution % Wireless Communication %
Other (describe):
%
Other (describe):
Installation
%
Miscellaneous Professional Services
(describe)
%
Cabling – Inside % Record Management/Retrieval %
Cabling – Outside % EDP Audit/Needs Evaluation %
Computers & Peripherals % Computer Security/Virus Services %
Software %
Other (describe):
%
Telecommunications Equipment %
Other (describe):
%
Other (describe):
%
Other (describe):
%
Other (describe): % Other (descriEH
%
1. Provide the following information regarding your five (5) largest clients.
(Determined as a percentage of the total gross revenue for the past fiscal year)
Client Size of Contract Length of Contract Description of Services
2. What is the percentage of sales to repeat customers: %
3. Rate the technical level of sophistication of your average customer: Novice Average Sophisticated
4. Are procedures in place to evaluate the financial condition and legitimacy of all new clients? Yes No
SECTION III - SERVICE / PRODUCTS ALLOCATION/DESCRIPTION OF OPERATIONS
(to be completed by all Applicants)
SECTION IV - CLIENT INFORMATION (to be completed by all Applicants)
Integrated Technology
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Individual Consumers %
United States Federal Government %
United States State and Local Governments %
Foreign Governments %
6. Indicate the percentage of revenue derived from the following business sectors.
Business Sector % of Receipts Business Sector % of Receipts
Aerospace & Defense % Healthcare %
Automobiles & Components % Information Technology %
Chemical % Manufacturing %
Construction & Engineering % Media %
Consumer Services % Oil, Gas & Utilities %
Electrical Equipment % Retail %
Energy Equipment & Services % Telecommunication %
Financial Services % Transportation %
7. Do you hold non-public information on behalf of your client(s)? Yes No
If yes, please complete Section IX, Information Security.
1.
Do you require the use of a written contract or agreement for all engagements?
Yes
No
What percent of contracts are in writing:
%
2.
Do you maintain and enforce a contractual review process?
Yes
No
3.
Does this process include review by legal counsel?
Yes
No
4.
Do you have a standard written contract that you use on most engagements?
Yes
No
5.
Indicate the percentage of contracts where your standard contract, the customer’s contract, or a
combination of both is used.
Standard:
%
Customer:
%
Combination:
%
6.
What contractual provisions do you strive to impose on most contracts? (select all that apply)
Disclaimer of Warranties
Hold Harmless to your Benefit
Dispute Resolution
Limitation of Liability
Exclusions for Consequential Damages
Performance Milestone
Exclusive Remedies
Statement of Work
Force Majeure
Venue or Governing Law
7.
Do you have a formal customer acceptance process in place?
Yes
No
8.
Are performance milestones accepted with signoffs by both parties?
Yes
No
9.
Are interim changes in contracts documented and signed off by both parties?
Yes
No
10.
Does anyone other than a principal have the authority to amend the standard contract?
Yes
No
If yes, who:
1.
Do you employ a Risk Manager?
Yes
No
If no, please indicate who is responsible for handling insurance related matters:
2.
Do you have policies and procedures in place to respond to customer complaints?
Yes
No
3.
Do you utilize an escalation procedure to respond to customer complaints?
Yes
No
4.
Indicate which of the quality control procedures are in place. (select all that apply)
Alpha Testing
Customer Service via E-Mail
Beta Testing
Formalized Training for New Hires
Business Continuity Plan
Prototype Development
Customer Screening Process
Vendor Certification Process
Customer Service via a Toll-Free Number
Written Quality Control Guidelines
Customer Service via a Web Portal
Other:
5.
Do you have a disaster recovery/business continuity plan?
Yes
No
How often do you test it:
6.
Do you backup network data and configure files daily?
Yes
No
If not daily, then how often are data and files backed up:
Do you store backup files in a secure location?
Yes
No
Where:
Onsite
Offsite
5. Indicate the percentage of products and services you provide to the following customer segments.
Customer Segment 3URGXFWV% of Services
Commercial Client %
SECTION V - CONTRACTUAL PROCEDURES (to be completed by all Applicants)
SECTION VI - QUALITY CONTROL PROCEDURES (to be completed by all Applicants)
Integrated Technology
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03/2018
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2.
If yes, what percentage do you sub-contract:
%
3.
Do you utilize a standard sub-contractor?
Yes
No
4.
Do you require evidence of General Liability from sub-contractors?
Yes
No
5.
Do you require evidence of Errors & Omissions insurance from sub-contractors?
Yes
No
Business Activities or Website Contents
% of
Receipts
Business Activities or Website Contents
% of
Receipts
Advertising/Marketing for Others
%
Music or Sound Clips
%
Executable programs or shareware
%
Pornographic or Sexually Explicit Material
%
File Sharing
%
Sweepstakes or Coupons
%
Interactive Gaming
%
Video Producers
%
Movie/Commercial Production
%
Other (describe):
%
Website Content Provider
%
Open Source
%
Content created by Applicant
%
Open Source Code originated by Applicant
%
Content supplied by Client
%
Open Source Code created by others and
used by Applicant
%
Domain Name Registration
%
1.
If you distribute computer systems with software included, are the appropriate license
agreements supplied with each system?
N/A
Yes
No
2.
Do you follow all contractual requirements when distributing hardware or software
manufactured by others?
N/A
Yes
No
3.
Is the ownership of intellectual property created by you, or on your behalf, clearly stated in
all customer contracts and followed by you?
N/A
Yes
No
4.
If you sell used equipment, are new license agreements purchased?
N/A
Yes
No
5.
Do you have a procedure for reviewing all content that is disseminated via your website?
Yes
No
6.
Does your website, or any website managed by you, include chat rooms, bulletin boards, or blogs?
Yes
No
If yes, do you review and edit prior to posting?
Yes
No
Do you have a formal procedure for removing controversial or infringing material?
Yes
No
7.
Have you received notification that any of your material or services infringe on the intellectual
property rights of others?
Yes
No
8.
Risk Management Procedures for all Media Activities
a.
Do you employ an in-house counsel who specializes in intellectual property rights?
Yes
No
b.
Do you have written intellectual property clearance procedures?
Yes
No
c.
Do you acquire all necessary rights, licenses or consent to use of content?
Yes
No
d. Do you require employees and contractors to sign a statement that they will not use previous
employers’ or clients’ intellectual property?
Yes
No
e. Do you have agreements in place with contractors, working on your behalf, granting you
ownership of all intellectual property developed for you?
Yes
No
1.
Have you dedicated at least one staff member to manage, on a full-time basis, information security
such as a Chief Information Security Officer or equivalent?
Yes
No
2. Do you have a written security policy that must be followed by all employees, contractors, or any
other person with access to your network?
Yes
No
3.
Have you established employee awareness and/or security training programs?
Yes
No
4.
Do you disclose a privacy policy and always honor it?
Yes
No
5.
Has your privacy policy been reviewed by:
Qualified Attorney
3
rd
Party (TRUSTe, eTrust)
Neither
1.
Do you sub-contract any professional services or manufacturing to fulfill commitments to clients?
Yes
No
SECTION VII - SUB-CONTRACTED WORK, USE OF SUPPLIERS AND OUTSOURCED MANUFACTURING
(to be completed by all Applicants)
SECTION VIII - MEDIA (Complete only if applying for Media Liability)
SECTION IX - INFORMATION SECURITY (Complete only if applying for Network Security & Privacy Liability
Coverage, or if you are responsible for non-public information on behalf of others.)
Integrated Technology
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© 2018 Philadelphia Consolidated Holding Corp.
03/2018
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6.
Please indicate which type of third party sensitive information resides in your network: (Select all that apply)
Credit card data for the duration of a transaction
Credit card data stored for future use (all but last four (4) digits masked)
Credit card data stored for future use (un-masked card numbers or including track two (2) data)
Private health information
Sensitive or proprietary company information (including trade secrets)
Other personally identifiable financial information (describe):
7.
a.
Do you use wireless networks?
Yes
No
b.
If yes, do you use security at least as strong as WPA authentication and encryption requiring
two factor authentication (e.g. some combination of VPN or Access Token, and password/
account logon) before allowing wire connections to the network?
Yes
No
c.
Have you established an internal security breach incident response team?
Yes
No
d.
Have you established a formal, written security breach response plan?
Yes
No
e.
Does the plan contain a process for assessing whether a breach notice is legally mandated?
Yes
No
f.
Does the plan contain a process regarding the proper means to communicate the breach?
Yes
No
TECHNICAL SECURITY
1.
a.
Do you implement virus controls on all of your systems?
Yes
No
b.
Please check all items that accurately describe this program.
Anti-Virus/malicious code software is deployed on all computing devices within your network
Automatic updates occur, at least daily
Anti-virus scans are performed on all e-mail attachments, files, and downloads before opening
Rejected files are quarantined
Unneeded services and ports are disabled
Virus/information security threat notifications are automatically received from CERT or similar
2.
a.
Do you have a firewall in place?
Yes
No
b.
Please check all items that accurately describe the firewall.
A formal process has been established for approving and testing all external network connections
A firewall has been established at each internet connection
A firewall has been established between any DMZ and intranet connection
3.
Do you install and configure anti-spyware software to provide maximum protection of personally
identifiable/sensitive information on all servicers, desktop PCs and laptops?
Yes
No
4.
Do you check for security software updates and patches at least weekly and implement them within
thirty (30) days?
Yes
No
ADMINISTRATIVE SECURITY
1.
Do you control access to information that resides on data storage devices such as servers,
desktops, PCs laptops, and PDAs?
Yes
No
2.
Do you control access to information that can be displayed, printed, and/or downloaded to external
storage devices?
Yes
No
3.
Are you able to identify whose non-public information is being held and how to contact individuals if
their information is breached?
Yes
No
4.
Do you monitor user accounts to identify and eliminate inactive users?
Yes
No
5. Do you use reasonable encryption methods when transmitting, receiving, or storing personally
identifiable/sensitive information?
Yes
No
6.
Do you replace factory default settings to ensure information security systems are securely
configured?
Always
Sometimes
Never
7.
Do you retain personally identifiable information only for as long as needed?
Always
Sometimes
Never
8.
Do you discard personally identifiable information when no longer needed by irreversibly
erasing or destroying the data using a technique that leaves no residual data?
Always
Sometimes
Never
9.
Do you require third parties to whom you entrust personally identifiable information to
contractually agree to protect such information using safeguards at least equivalent to your
own?
Always
Sometimes
Never
Integrated Technology
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10.
Does your hiring process include conducting background checks on employees and
independent contractors?
Always
Sometimes
Never
PHYSICAL SECURITY
1.
Have you established physical security controls to control access to sensitive data?
Yes
No
2.
Do you limit server, server room and data center access only to authorized personnel?
Yes
No
3.
a.
Do your removable devices such as laptops, PDAs, thumb drives, tapes or diskettes
(removable media) contain non-public personal or commercial information?
If yes, attach a detailed description of the type of information contained on these devices.
Yes
No
b. Do you encrypt personally identifiable information stored on removable media? Always
Sometimes
Never
4.
Do you have an established procedure for employee departures that includes an inventoried
recovery of all information assets, user accounts, and systems previously assigned to each
individual during their period of employment?
Yes
No
1.
Do you have any account receivables for professional or technology service contracts that are
more than ninety (90) days past due?
Yes
No
If yes, attach details.
2. Within the past five (5) years, have you sued any customers for non-payment of any contract or
licensing fee?
Yes
No
If yes, attach details.
3.
Within the past five (5) years, have any customers withheld payment or requested a refund of fees
because your products/services
a.
did not meet customer’s performance expectations?
Yes
No
b.
did not perform in compliance with your warranty or guarantee?
Yes
No
If yes, attach details.
1.
Have any technology errors and omissions, media liability, or network security/privacy injury claims
been made during the past five (5) years against you?
Yes
No
If yes, attach a detailed summary, including the name of the claimant, the date the claim occurred,
the date it was reported, the demand amount, whether the claim is open or closed, and the amount
paid by both the insured and insurance.
2. Does your Chief Executive Office, Chairperson, Chief Financial Officer, President, or Risk Manager
have knowledge, information of any circumstance, or any allegation of contentions of any incident
that could give rise to a claim that would be covered by this policy?
Yes
No
If yes, attach a detailed summary, including the name of the claimant, the date the claim occurred,
the date it was reported, the demand amount, and any other pertinent details.
3.
Have you received any complaints, claims, or been subject to litigation involving matters of privacy
injury, identity theft, denial of service attacks, computer virus infections, theft or information,
damage to third party networks or your customers ability to rely on your network?
Yes
No
If yes, attach details.
4.
Within the last five (5) years, have you been the subject of an investigation or action by any
regulatory or administrative agency arising out of your business practices?
Yes
No
If yes, attach details.
SECTION X - HISTORICAL BUSINESS INFORMATION (to be completed by all Applicants)
SECTION XI - HISTORICAL CLAIMS & INVESTIGATORY INFORMATION
(to be completed by all Applicants)
Integrated Technology
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FRAUD STATEMENT 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 collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
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.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE)
____________
_________________________________________________
SIGNATURE DATE
SECTION
TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
TITLE
(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR OFFICER)
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