Media
Application form
United States
APPLICATION FORM
INTRODUCTION
The purpose of this application form is for us to find out who you are and to obtain information relevant to the cover provided by
the MEDIA policy. Completion of this application form does not oblige either party to enter into a contract of insurance. Insurance
is a contract of utmost good faith. This means that the information you provide in this application form must be complete, accurate
and not misleading. It also means that you must tell us about all facts and matters which may be relevant to our consideration of
your application for insurance. Any failure by you in this regard may entitle us to treat this insurance as if it never existed. If a contract
of insurance is agreed between you and us this application form will form the basis of the contract.
Important: Insuring Clauses 1, 2, 3, 4 and 6 (sections E and H only) of this policy provide cover on a claims made basis. Under these
insuring clauses any claim must be first made against the insured and notified to us during the period of the policy to be covered.
These insuring clauses do not cover any claim arising out of any actual or alleged wrongful act occurring before the retroactive date.
HOW TO COMPLETE THIS FORM
Whoever fills out the form must be a principal, partner or director of the applicant firm and should make all the necessary enquiries
of their fellow partners, directors and employees to enable all the questions to be answered. Once you have completed the form
please return it directly to your insurance agent.
If you require any extra space to complete the answers to questions contained within this application form please continue your
response in the additional information section at the back of the form.
MEDIA
INSURANCE FOR MEDIA COMPANIES
SECTION 1: COMPANY DETAILS
1.1 Please state the name and address of the principal company for whom this insurance is required. Cover is also provided for the
subsidiaries of the principal company, but only if you include the data from all of these subsidiaries in your answers to all of the
questions in this form:
Insured company:
Contact name:
Address:
ZIP code:
Telephone: Email address:
Fax: Website:
1.2 Please state when your company was established:
1.3 a) How many principals / directors / officers / partners are there in the company?
b)
Please sho
w the details of all principals / partners / directors:
Name Years in position Years experience Qualifications
MM / DD / YY
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
c) Please state the number of employees:
1.4 Please state the following:
Last complete Estimat
e for current Estimate for next
financial year financial year financial year
Domestic revenue:
Other territory revenue:
Total revenue:
Gross profit:
Payroll:
Date of financial year end: Currency:
SECTION 2: ACTIVITIES
2.1 Please briefly describe below the nature of your business activities:
If you have a brochure, or company literature, please attach to this form.
2.2 Please provide a full breakdown of your total revenue by activity:
The total of all ac
tivities listed here should equal 100%.
2.3 Do your activities include event or conference organizing? Yes No
If ‘y
es’, please provide details of the type of events organized below:
MM / DD / YY
%
%
%
%
%
%
%
%
%
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
CFC MED US V1.1
2.4 Do your activities include filming on location in an area to which the public have access? Yes No
If ‘yes’, please provide details below:
2.5 Do your activities include rigging or set construction? Yes No
If ‘yes’, please pr
ovide details below:
2.6 Do any of your employees engage in manual work? Yes No
If ‘yes’, please st
ate the percentage of your overall payroll that relates to manual work:
2.7 Do any of your employees work at a height in excess of 10 metres? Yes No
If ‘y
es’, please pr
ovide more details below:
2.8 Please list all of your current public facing URLs:
URL Natur
e of Estimated current Estimated monthly
website monthly unique unique visitors over
visitors the next 12 months
2.9 Do you seek explicit consent from all third parties before selling or sharing their
personall
y identif
iable data? Yes No
2.10 Do you have a privacy policy and terms of use on your website? Yes No
If ‘yes’, has it been leg
ally reviewed? Yes No
If you have answered ‘no’ to either of the above questions, please explain below:
%
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
2.11 Do you have a specific policy for managing all “opt-in”/ “opt-out” marketing requests? Yes No
If ‘no’, then please explain:
2.12 Do your internal IT systems comply with all of our minimum security requirements detailed below? Yes No
Anti-virus sof
tware must be installed on all desktops and servers (excluding database servers)
and updated on at least a weekly basis;
All external network gateways must be protected by a firewall;
All critical data must be backed up on at least a weekly basis;
All back-ups should be stored in a secure location offsite or in a fireproof safe; and
The integrity of all back-ups should be verified on at least a monthly basis.
If ‘no’, then please explain:
2.13 In the event of a system interruption (including web downtime), what is your maximum estimated daily
f
inancial loss?
Not
e: This figure will set the maximum limit for your system business interruption cover.
2.14 Please detail which of the following data types you collect:
Cr
edit or debit card details Yes No
Social security numbers Yes No
Credit history or ratings Yes No
Medical records or health information Yes No
Customer bank records or details Yes No
Third party corporate confidential data Yes No
SECTION 3: CONTRACT INFORMATION
Only complete this section if you require professional liability cover.
3.1 Please give details of the 5 largest contracts you have carried out in the past 3 years:
Name Business Natur
e of your work Your annual revenue Start Completion
of client of client undertaken for this contract from this contract date date
3.2 Approximately how many clients do you have?
MM / YY
MM / YY
MM / YY
MM / YY
MM / YY
MM / YY
MM / YY MM / YY
MM / YY
MM / YY
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
3.3 Do you carry out work only under a written contract signed by every client? Yes No
Please supply a copy of your standard form of contract, or typical examples of contracts used.
If ‘no’, please explain in what circumstance and why:
3.4 Do you ever accept contracts with your customers in which you accept liability for
consequential loss or financial damages gr
eater than the value of the contract? Yes No
If ‘yes’, please explain what percentage of your contracts this is applicable to and what these are capped at:
3.5 What approximate percentage of your revenue, in your current financial year, will be paid to sub-contractors? %
3.6 Do you ensure that sub-contractors have their own commercial general liability and errors and omissions
insurance? Ye
s
N o
If ‘no’, please explain how you limit your exposure?
3.7 Are all your contracts reviewed by an appropriately qualified legal advisor prior to signature? Yes No
If ‘no’, who signs of
f the contract?
3.8 Do you always obtain client sign off on your deliverables? Yes No
If ‘no’, please explain:
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
SECTION 4: PUBLISHING ACTIVITIES & RISK MANAGEMENT
4.1 Please list all of your current publications:
Name Geographical Date first Average Frequency of
distribution* published circulation publication
* e.g. regional, national or international
4.2 Do you engage in any investigative journalism or publish exposé content? Yes No
If ‘yes’, please pr
ovide details:
4.3 Do you have standard procedures and safeguards for:
a) ensuring accura
cy and originality of content? Yes No
b) processing unsolicited ideas, photographs, articles, clippings etc.? Yes No
c) clearing titles of all publications? Yes No
If ‘no’, please explain why:
4.4 Does your company use content supplied by third parties? Yes No
If ‘y
es’, do you obtain written warranties in respect of originality of content, accuracy of
content and authenticity of source? Yes No
If ‘no’, please explain why:
4.5 Do you obtain written releases with respect to creative material or talent from
emplo
y
ees, models, freelance photographers, writers, composers, artists, musicians or
non-professional persons appearing in commercial advertisements: Yes No
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
4.6 Do you have a written procedure for ensuring all appropriate licensing fees are paid
with respect to any music that you use? Yes No
If ‘no’, please explain why:
4.7 Please provide the name of the law firm you consult in respect of media issues, including review, procedures and complaints
handling:
4.8 Is all advice adhered to? Ye
s No
If ‘no’, please explain under what circumstances:
4.9 Do you have written procedures to either edit, remove or respond to offending, inappropriate, Yes No
inaccurat
e or infringing content, including website content?
4.10 Do you engage in comparative advertising? Yes No
If ‘yes’, please explain y
our procedures to ensure accuracy of content:
4.11 Do you trademark your proprietary products? Yes No
If ‘no’, please explain wh
y:
4.12 Do you engage the services of an advertising agency? Ye s
N o
If ‘yes’, do they provide you with a full indemnity in relation to all of the content they originate? Yes No
4.13 In the event of a system interruption (including web downtime), what is your maximum estimated daily
financial loss?
Not
e: This figure will set the maximum limit for your system business interruption cover.
4.14 Do you ensure that all sensitive data is encrypted while standing and during transmission? Yes No
4.15 Do you outsource the handling of sensitive data to any third party? Yes No
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
SECTION 5: PROPERTY & BUSINESS INTERRUPTION INSURANCE
Only complete this section if you require this cover.
5.1 Please state the address of the premises to be insured (if different from the address given earlier):
PREMISES 1
Addr
ess:
ZIP code:
PREMISES 2
Address:
ZIP code:
Please continue on a separate sheet if more than 2 premises are to be insured.
5.2 Please detail below any other party (such as a bank or building society) whose financial interest in the premises should be noted
on the policy:
Name of par
ty:
Int
erest of party:
Address:
ZIP code:
5.3 Are all of the premises:
a) Construct
ed with external walls of brick, stone or concrete and roofed with slate, tiles,
concrete, metal, asbestos or any other non-combustible material? Yes No
b) Free from cracks or other signs of damage that may be due to subsidence, landslip or heave
and have not previously suffered damage by any of these causes? Yes No
c) In a good state of repair? Ye s N o
d) Self contained with a lockable entrance door? Yes No
e) Protected by an intruder alarm that is subject to an annual maintenance contract? Yes No
NOTE: We may refuse to pay a claim if all of the devices for the security of your premises (including locks and the intruder alarm)
are not put into full and effective operation whenever the premises are closed for business or left unattended.
f) Heated by a conventional electric, gas, oil or solid fuel heating system? Yes No
g) Fitted with electrical installations which are inspected at least every 5 years by a qualified
electrician and any defect remedied? Yes No
h) Lifts, boilers, steam and pressure vessels inspected and approved to comply with all of
the statutory requirements? Ye s N o
i) Sprinklered, either fully or partially? Yes No
NOTE: Assuming you have answered ‘yes’ to questions h) and i) above, it is important to keep records of all relevant inspections as we
may ask for evidence of these before paying a claim.
If you have answered ‘no’ to any of the above questions then please give further details:
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
%
%
SECTION 6: INSURANCE REQUIREMENTS
6.1 Please provide details of your current or required insurance policies (unless you are already insured with CFC):
Type of Inception/ Limit of Deductible Premium Insurer Retroactive
insurance expiry date liability date (if known)
Media liability:
Errors & Omissions:
Cyber/privacy liability:
Commercial General
Liability:
Property:
6.2 Please detail the amounts to be insured below for each premises (complete only if you require property cover).
NO
TE
: The amounts insured you state below should be the full rebuilding or replacement cost in each of the categories. If you understate
these amounts you will be under-insuring and we may not pay the full amount of your claim. It is therefore essential that these amounts are
as close to the true values of the insured items as possible.
ITEM AMOUNT INSURED PREMISES 1 AMOUNT INSURED PREMISES 2
Main building:
Landlord’s fixtures & fittings
and tenant improvements:
All items wherever located
1
:
1
Please list any alternative locations in question 5.1
6.3 If you have portable electronic equipment (such as laptops, cameras, video equipment) that is either
permanently or t
emporarily away from your premises please state the total value of these items:
Please also state the approximate percentage of the time that these items are away from your premises:
6.4 If you have contents other than portable electronic equipment which are either permanently or
t
emporaril
y away from your premises please state the total value of these items:
Please also state the approximate percentage of the time that these items are away from your premises:
6.5 Please detail the amounts to be insured below for business interruption cover (complete only if you require this cover):
Not
e that the maxim
um indemnity period available is 12 months. You should bear in mind how long it will take you to re-commence
trading at another premises when stating the amount insured and indemnity period.
We provide our business interruption cover on a ‘Flexible First Loss’ basis – please specify a total amount insured for business
interruption cover. This amount applies regardless of whether your business interruption loss is loss of revenue, costs and
expenses, loss of research and development expenditure, project delay costs or outstanding debts. This often enables a smaller
total amount insured to be specified and therefore often results in a cheaper premium.
ITEM AMOUNT INSURED INDEMNITY PERIOD
Business interruption cover (‘Flexible First Loss’): Months
MM / YY
MM / YY
MM / YY
MM / YY
MM / YY
MM / YY
N/A
N/A
MM / YY
MM / YY
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
MM / DD / YY
SECTION 7: CLAIMS EXPERIENCE & INSURANCE HISTORY
7.1 Regarding all of the types of insurance to which this application form relates AFTER FULL INQUIRY:
a) are you aware of any loss or damage, whether insured or not, that has occurred to any of the companies to be insured (or
to any existing or previous business of the partners or directors of any of the companies to be insured) within the last 5
years, or
b) are you aware of any circumstances which may give rise to a claim against any of the companies to be insured or any partners
or directors thereof, or
c) have any claims or cease and desist orders been made against any of the companies to be insured, or partners or directors
thereof, or
d) have any partners or directors of the companies to be insured been found guilty of any criminal, dishonest or fraudulent
activity or been investigated by any regulatory body, or
e) has there ever been an unforeseen outage to your website for more than 3 hours?
With reference to questions a, b, c, d and e above: Yes No
If the answer to the above is ‘yes’ then please attach full details including an explanation of the background of events, the
maximum amount involved or claimed, the status of the claims or circumstances and any reserves or payments made by you or
by insurers, and the dates of all developments and payments.
SECTION 8: DECLARATION
I declare that after proper enquiry the statements and particulars given above are true and that I have not mis-stated or
suppressed any material fact.
I agree that this application form, together with any other material information supplied by me shall form the basis of any
contract of insurance ef
fected thereon.
I undertake to inform underwriters of any material alteration to these facts occurring before the completion of the contract.
Signed: Full name:
P
osition held: Date:
CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
ADDITIONAL INFORMATION:
CFC
Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority
©1999-2012 CFC Underwriting Ltd, All Rights Reserved
CFC MED US V1.0
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