Fillable INTEGRATED TECHNOLOGY RENEWAL APPLICATION (Philadelphia Insurance Companies)

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INTEGRATED TECHNOLOGY RENEWAL APPLICATION (Philadelphia Insurance Companies)

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INTEGRATED TECHNOLOGY RENEWAL APPLICATION
SUBMISSION REQUIREMENTS
•
Copies of your current contracts or license agreement if they have been revised
•
Current audited financial statement
•
Updated 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:
SECTION I - COVERAGES (to be completed by all Applicants)
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. Renewal date (mm/dd/yyyy):
3. Expiring coverage
Coverage Technology E&O Media Liability
Network Security/
Privacy Injury
Policy Period
Limit of Liability $ $ $
Retention $ $ $
Retroactive Date
Premium $ $ $
SECTION II - REVENUE (to be completed by all Applicants)
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
8. Risk Management’s Phone: Risk Management Contact:
Risk Management Email:
PI-TECH-007 Non-Admitted
Application - Integrated Tech E&O Renewal
Page 1 of 6
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
Clear Application
Print Application
SECTION III - SERVICE / PRODUCTS ALLOCATION / DESCRIPTION OF OPERATIONS
(to be completed by all Applicants)
1.
Explain any change in Operations in the past twelve (12) months:
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 (other than computers)
Manufacturer
%
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):
%
Installation %
Miscellaneous Professional Services
(describe)
%
Other (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):
%
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
: Other (describe):
SECTION IV CLIENT INFORMATION (to be completed by all Applicants)
PI-TECH-007 Non-Admitted
Application - Integrated Tech E&O Renewal
Page 2 of 6
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
Print Application
Clear Application
2.
Indicate the percentage of products and services you provide to the following customer segments.
Customer Segment
% of Services / Products
Commercial Client
%
Individual Consumers
%
United States Federal Government
%
United States State and Local Governments
%
Foreign Governments
%
3.
Indicate the percentage of products and services you provide to the following customer segments.
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
%
4.
Do you hold non-public information on behalf of your client(s)?
Yes
No
If yes, please complete Section IX, Information Security.
SECTION V - CONTRACTUAL PROCEDURES (to be completed by all Applicants)
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.
Indicate the percentage of contracts where your standard contract, the customer’s contract, or a
combination of both is used.
Standard:
%
Customer:
%
Combination:
%
3.
Are interim changes in contracts documented and signed off by both parties?
Yes
No
SECTION VI - QUALITY CONTROL PROCEDURES (to be completed by all Applicants)
1.
Do you have a disaster recovery/business continuity plan?
Yes
No
How often do you test it:
2.
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
SECTION VII - SUB-CONTRACTED WORK, USE OF SUPPLIERS AND OUTSOURCED MANUFACTURING
(to be completed by all Applicants)
1.
Do you sub-contract any professional services or manufacturing to fulfill commitments to clients?
Yes
No
2.
If yes, what percentage do you sub-contract:
%
3.
Do you require evidence of Errors & Omissions insurance from sub-contractors?
Yes
No
SECTION VIII - MEDIA (Complete only if applying for Media Liability or Copyright of Software Code
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
%
PI-TECH-007 Non-Admitted
Application - Integrated Tech E&O Renewal
Page 3 of 6
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
Print Application
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1.
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
2.
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
3.
Risk Management Procedures for all Media Activities
a.
Do you have written intellectual property clearance procedures?
Yes
No
b.
Do you have agreements in place with contractors, working on your behalf, granting you
ownership of all intellectual property developed for you?
Yes
No
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.)
1.
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
2.
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):
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
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
1. Do you limit server, server room and data center access only to authorized personnel?
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.
1. 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 of information,
damage to third party networks or your customers ability
to rely on your network?
Yes
No
If yes, attach details.
PHYSICAL SECURITY
SECTION X - HISTORICAL BUSINESS INFORMATION
SECTION XI - CLAIMS & INVESTIGATORY INFORMATION
PI-TECH-007 Non-Admitted
Application - Integrated Tech E&O Renewal
Page 4 of 6
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
Print Application
Clear Application
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) TITLE
(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR OFFICER)
______________
______________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Address (Street, City, State, Zip)
Resident or Non-Resident Surplus Lines Licensee Information for Applicant’s State of Domicile
SL License State SL License No.
Agency Taxpayer ID or SS Number
PI-TECH-007 Non-Admitted
Application - Integrated Tech E&O Renewal
Page 5 of 6
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
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NOTICE
1. THE INSURAN
CE POLICY THAT YOU ARE APPLYING TO PURCHASE IS BEING ISSUED BY AN INSURER THAT
IS NOT LICENSED BY THE STATE OF CALIFORNIA. THESE COMPANIES ARE CALLED “NONADMITTED” OR
“SURPLUS LINE” INSURERS.
2. THE INSURER I
S NOT SUBJECT TO THE FINANCIAL SOLVENCY REGULATION AND ENFORCEMENT THAT
APPLY TO CALIFORNIA LICENSED INSURERS.
3. THE INSURER DO
ES NOT PARTICIPATE IN ANY OF THE INSURANCE GUARANTEE FUNDS CREATED BY
CALIFORNIA LAW. THEREFORE, THESE FUNDS WILL NOT PAY YOUR CLAIMS OR PROTECT YOUR ASSETS IF
THE INSURER BECOMES INSOLVENT AND IS UNABLE TO MAKE PAYMENTS AS PROMISED.
4. CALIFO
RNIA MAINTAINS A LIST OF ELIGIBLE SURPLUS LINE INSURERS APPROVED BY THE INSURANCE
COMMISSIONER. ASK YOUR AGENT OR BROKER IF THE INSURER IS ON THAT LIST, OR VIEW THAT LIST AT
THE INTERNET WEB SITE OF THE CALIFORNIA DEPARTMENT OF INSURANCE: www.insurance.ca.gov.
5. FOR ADDITIONAL INFORMATION ABOUT THE INSURER YOU SHOULD ASK QUESTIONS OF YOUR INSURANCE
AGENT, BROKER, OR “SURPLUS LINE” BROKER OR CONTACT THE CALIFORNIA DEPARTMENT OF
INSURANCE, AT THE FOLLOWING TOLL-FREE TELEPHONE NUMBER: 1-800-927-4357.
6. IF YOU
, AS THE APPLICANT, REQUIRED THAT THE INSURANCE POLICY YOU HAVE PURCHASED BE BOUND
IMMEDIATELY, EITHER BECAUSE EXISTING COVERAGE WAS GOING TO LAPSE WITHIN TWO BUSINESS
DAYS OR BECAUSE YOU WERE REQUIRED TO HAVE COVERAGE WITHIN TWO BUSINESS DAYS, AND YOU
DID NOT RECEIVE THIS DISCLOSURE FORM AND A REQUEST FOR YOUR SIGNATURE UNTIL AFTER
COVERAGE BECAME EFFECTIVE, YOU HAVE THE RIGHT TO CANCEL THIS POLICY WITHIN FIVE DAYS OF
RECEIVING THIS DISCLOSURE. IF YOU CANCEL COVERAGE, THE PREMIUM WILL BE PRORATED AND ANY
BROKER’S FEE CHARGED FOR THIS INSURANCE WILL BE RETURNED TO YOU.
Insured: _________________________________________ D
ate:
PI-TECH-007 Non-Admitted
Application - Integrated Tech E&O Renewal
Page 6 of 6
© 2018 Philadelphia Consolidated Holding Corp.
04/2018
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INTEGRATED TECHNOLOGY RENEWAL APPLICATION (Philadelphia Insurance Companies)

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Completed 7 November 2020

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