Fill - Free fillable MED Application US V1.1 Layout 1 PDF form

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?

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

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

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

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

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:

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

CFC

Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority

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

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

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

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

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

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

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

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).

: 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

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

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

N/A

MM / YY

CFC

Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority

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:

osition held: Date:

CFC Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority

CFC MED US V1.0

ADDITIONAL INFORMATION:

CFC

Underwriting Limited is Authorised and Regulated by the Financial Conduct Authority

CFC MED US V1.0

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