Claims made disclosure - The Travelers Companies€¦ · Web viewLIABILITY COVERAGE APPLIES ON A CLAIMS-MADE BASIS. ... Evaluation of all outstanding contracts or service agreements

CYBERFIRSTSM APPLICATION

LIABILITY COVERAGE APPLIES ON A CLAIMS-MADE BASIS. DEFENSE EXPENSES WILL BE APPLIED AGAINST THE RETENTION. DEFENSE EXPENSES ARE PAYABLE WITHIN, AND ARE NOT IN ADDITION TO, THE LIMITS OF INSURANCE. PAYMENT OF DEFENSE EXPENSES WILL REDUCE, AND MAY EXHAUST, THE LIMITS OF INSURANCE. PAYMENTS MADE UNDER THE EXPENSE REIMBURSEMENT COVERAGE FORM, IF THAT FORM IS PART OF YOUR POLICY, WILL ALSO REDUCE, AND MAY EXHAUST, THE LIMITS OF INSURANCE.IT IS IMPORTANT THAT YOU CAREFULLY READ ALL OF THE PROVISIONS OF ANY POLICY ISSUED AS A RESULT OF THIS APPLICATION.

Answer each question on behalf of all entities seeking insurance coverage, unless specifically requested otherwise. An Additional Information section is provided at the end of this application for you to include any necessary information that exceeds the space provided.

GENERAL INFORMATION

First Named Insured:

Years in Business:

Mailing Address: Web Address(es): If any of the websites listed have a password protected member or subscriber area, provide temporary passwords and IDs or other information that will allow us to review the information contained on and the purpose of these websites.Proposed Effective Date (mm/dd/yyyy):

ORGANIZATION AND FINANCIAL INFORMATION1. Do you have any subsidiaries, partnerships or joint ventures for which coverage is requested?............... Yes No

If yes, the word “you” or “your” used hereunder will refer to all identified entities in addition to the first Named Insured. Please list such entities, along with their connection to the first Named Insured, in Additional Information section at the end of this application. Also list in Additional Information section any such entities for which coverage is not requested (if any) and identify where that entity’s insurance is placed.

2. Have you been involved in a merger, acquisition or divestiture within the past five years? ....................... Yes NoIf yes, identify in Additional Information section at the end of this application, the dates of the transaction and whether you acquired or retained assets or liabilities (or both) applicable to each transaction.

3. If you were to consider a future merger or acquisition of another entity, which of the following activities would be included in your standard due diligence process?a. Review of prior and pending litigation.................................................................................................. Yes Nob. Evaluation of all outstanding contracts or service agreements that will be included as part

of transaction....................................................................................................................................... Yes Noc. Analysis of intellectual property rights of such entity, including any third party interest in,

or liens on, those rights........................................................................................................................ Yes No

4. Identify your most recent and projected fiscal year-end (FYE) revenue*:Source Most Recent FYE Revenue Projected FYE Revenue

Total United States Revenue $ $ Total Foreign Revenue $ $ Total Revenue $ $

*For this purpose, revenue means the gross income of a nonprofit or for-profit entity. Revenue does not include investment income, intra-entity revenue or returns from overpayment of taxes. Examples of revenue include income

58970 Rev. 01-17 © 2016 The Travelers Indemnity Company. All rights reserved. Page 1 of 11

sources such as: sales, receipts, fees, commission, donations, contributions, dues, grants received by nonprofit and membership organizations, and other type of income of nonprofit or for-profit entities.

5. Provide an estimate of the current percentage of revenue for each activity that applies. Also, check each projected business activity expected in the next year:

Current Percentage Of Revenue

Projected Activity Within

One YearInformation Technology (IT) Outsourcing (including IT staff augmentation, help desk or other maintenance and support of the systems of others) %

Data Processing Services (other than credit card processing) %

Credit Card Processing Services %

Call Center Services – Inbound and Outbound %

Document Imaging Software Services (including records management / storage) %

Content Development Services (including website, prepackaged, custom software and mobile applications development) %

Information Systems Disaster Recovery Services or Consulting %

Network Security or Authentication Services, Information Systems Security Software, Hardware or Service %

Physical Security Software, Products or Solutions %

ERP, CRM, Supply Chain or Similar Software and Services (including consulting) %

Internet Service or Access Provider, Telecommunications Services (including wireline, VoIP and wireless) %

Contract Research Organization (including Clinical Research Organizations) %

Website or Server Hosting for Others (including cloud or software/ infrastructure/ platform as a service) %

Colocation or Data Center Services %

Design, Manufacture, or Sale of Electronics or Components %

Design, Manufacture, or Sale of Medical Products %

Design, Manufacture, or Sale of Process Control Software, Systems or Components %

Contract Manufacturing for Others %

Marketing Services (including targeted or behavioral marketing, search engine optimization, social media and sale of third party data) %

Advertising Services (including campaign development, logo design, branding, and advertising placements for third parties) %

Media Content Aggregation or Publication Services %

Other: %

100%


REQUESTED INSURANCE TERMS AND CURRENT INSURANCE INFORMATION6. If this is an application for new coverage, please complete this entire section. However, if this is a renewal

application, please complete those sections in which you are requesting coverage that differs from your expiring program.

Third Party Liability Insuring Agreements Requested Coverage

Requested Retroactive Date

Requested Each Wrongful Act Limit

Requested Retention

Errors And Omissions Liability Yes $ $ Communications And Media Liability Yes $ $ Network And Information Security Liability Yes $ $

First Party Insuring Agreements Requested Coverage

Requested Limit Of Insurance

Requested Retention or

Waiting Period

Security Breach Notification And Remediation Expenses Yes $ $ Crisis Management Service Expenses Yes $ $ Business Interruption And Extra Expenses Yes $ HoursIT Provider – Contingent Business Interruption And Additional Expenses

Yes $ Hours

Outsource Provider – Contingent Business Interruption And Additional Expenses

Yes $ Hours

Extortion Expenses Yes $ $ Computer Program and Electronic Data Restoration Expenses Yes $ $ Computer Fraud Yes $ $ Funds Transfer Fraud Yes $ $ Telecommunications Theft Yes $ $

Optional Coverages Requested Requested Limit of Insurance

Limited Regulatory Action Yes $ Payment Card Expenses Yes $

PERSONNEL POLICIES AND PROCEDURES 7. Do you train employees in the proper use of each of the following resources: email,

Internet including social media accounts, strong password creation, and other security and incident response policies and procedures?.............................................................................................. Yes No

8. Do you have a written information security policy that you require all independent contractors,third party vendors and any other person or organization with access to your network to follow?............. Yes NoIf yes, do you require annual (or more frequent) review of those policies?................................................ Yes No

9. Do you have an established procedure to terminate all network access and user accounts that ispart of the standard exit process when any independent contractor or third party vendor or employee is terminated from a project?..................................................................................................... Yes No

10. Does your hiring process require a full background check for:All new employees? All independent contractors?

11. What percentage of your services are provided by independent contractors? % Please attach a detailed explanation of services in Additional Information section at the end of this application.

12. Do the independent contractors work under your direction?...................................................................... Yes No

13. Do you require independent contractors to provide proof of professional liability/cyber coverage?........... Yes No


If yes, do you require independent contractors to list you as an additional insured? ................................. Yes NoTECHNOLOGY ERRORS AND OMISSIONS LIABILITY

14. Please provide information about your current insurance for Errors and Omissions Liability Coverages (if any):Policy Period

(mm/dd/yyyy-mm/dd/yyyy)Insurance Company

Limit Retention Retroactive Date

(mm/dd/yyyy)

Premium

$ $ $

15. Within the past five years, have any of the coverages been declined, cancelled or not renewed? ......... Yes No (Not applicable in Missouri)If yes, attach detailed explanation or describe in Additional Information section at the end of this application.

16. Identify the principal markets for your products or services (check all that apply):AutomotiveAviation/Aircraft/AerospaceEducationEmergency Services (e.g., 911, fire) Energy/UtilitiesEntertainment/GamingFinancial Services (including banking, insurance or investment services)Government (for military or defense application)Government (for non-military application)

Healthcare/MedicalIndustrial/Factory AutomationMedia/AdvertisingProfessional Services (e.g., legal, accounting, medical or other services provided by licensed professionals)RetailTechnology CompaniesTelecommunication CompaniesOther:

17. Have any of your products, services or operations been discontinued or recalled within the last fiveyears?........................................................................................................................................................ Yes NoIf yes, provide details regarding the products, services or operations that have been discontinued or recalled, including procedures for informing customers in Additional Information section at the end of this application.

18. Do your standard procedures include providing continuing services, support or other remedy for products or services that you discontinue?................................................................................................ Yes No

CONTRACT PROCEDURES19. Do you require written contracts or agreements with all customers?......................................................... Yes No

If no, explain with which customers you require written contracts or agreements:

20. Do you require all modifications or mid-term changes to a contract be made in writing?........................... Yes NoIf no, identify when you would not require changes to be in writing:

21. Do your standard contracts or service agreements contain the following provisions?a. Arbitration Clause................................................................................................................................ Yes Nob. Conditions of Customer Acceptance of Product or Service................................................................. Yes Noc. Customer Maintenance Provision........................................................................................................ Yes Nod. Disclaimer of Warranties...................................................................................................................... Yes Noe. Exclusive Remedy............................................................................................................................... Yes Nof. Force Majeure...................................................................................................................................... Yes Nog. Integration Clause................................................................................................................................ Yes Noh. Limitation of Liabilities.......................................................................................................................... Yes Noi. Limitation of Liabilities for Consequential Damages............................................................................ Yes Noj. Scope of project or services……………………………………………………………..................……….. Yes No

22. What percentage of your customer contracts or service agreements deviate from, and do not contain all of, your standard provisions? (i.e., contractual provisions identified in question #21) %

23. Who can approve any variation in standard contract or service agreement provisions?In-house counsel Other:


24. Do you ever enter into contracts or service agreements with customers where you accept liabilityfor consequential damages?...................................................................................................................... Yes NoIf yes, identify the situations in which you accept liability for consequential damages and how often in Additional Information section at the end of this application.

25. Do you ever enter into contracts or service agreements with customers that include a provisionfor liquidated damages?............................................................................................................................. Yes No

26. Do you enter into contracts or service agreements that include a fixed time frame for completion ofall or portions of the project?...................................................................................................................... Yes No

27. Do you require written customer sign-off and acceptance at all milestones?............................................. Yes No

28. Do your sales and marketing staff receive training regarding each contractual provision that are in your standard contracts or service agreements? (i.e., contractual provisions identified in question #21).......... Yes No

29. What is the average size of your contracts currently in force?

Length (Average # of Months) Average Amount $

30. Identify your three largest contracts, projects or licensing agreements currently in force:Customer

(Type or Name)Length

(Average # of Months)Average Amount Service Provided

$ $ $

PRODUCT DEVELOPMENT/QUALITY CONTROL31. Do you have a written system development methodology or quality control procedure?........................... Yes No

32. Do your quality control procedures include the following?a. Alpha testing........................................................................................................................................ Yes Nob. Beta testing.......................................................................................................................................... Yes Noc. Pre-Release testing for malicious code or other security flaws............................................................ Yes Nod. Vendor certification process................................................................................................................. Yes Noe. Prototype development guidelines....................................................................................................... Yes Nof. Formal customer acceptance (upon delivery or completion of your product or services).................... Yes No

33. Do you comply with any the following industry standards?........................................................................ Yes NoIf yes, check all that apply:

ISO 9000 or later series UL/CSA ANSI CE Mark Other

34. Do you have a post-project evaluation or review procedure in place?....................................................... Yes NoIf no, identify your procedure for evaluating customer satisfaction with product or service in Additional Information section at the end of this application.

35. Do you obtain final customer approval in writing upon completion of your project or work?....................... Yes NoIf no, provide details in Additional Information section at the end of this application.

36. Do you have a formal policy in place for handling customer complaints or requests for changes or fixesthat includes your retention of all customer complaints or requests?......................................................... Yes No

37. Do you have an escalation process in place to resolve all customer complaints or requests?................... Yes No

38. Do you have a written dispute resolution policy?....................................................................................... Yes NoIf yes, attach a copy or explain your policy in Additional Information section at the end of this application.

39. Within the past five years, have you or your independent contractors experienced any projectdelays or past due contract issues with any customer?............................................................................. Yes NoIf yes, provide details, including your policy for handling, in Additional Information section at the end of this application.


NETWORK AND INFORMATION SECURITY LIABILITY

Network And Information Security Liability Coverage is not requested. (If this box is checked, skip this section. Move to page 8.)

40. Provide information about your current insurance for Network and Information Security Liability or Cyber (if any):Policy Period

(mm/dd/yyyy-mm/dd/yyyy)Insurance Company


(mm/dd/yyyy)

Premium

$ $ $

41. Within the past five years, have any of the coverages been declined, cancelled or not renewed? ........... Yes No(Not applicable in Missouri)If yes, attach detailed explanation or describe in Additional Information section at the end of this application.

42. Do you collect, receive, process, transmit, or maintain private, sensitive, or confidential information from third parties (i.e., customers, patients, consumers) as part of your business activities?.................... Yes NoIf yes, indicate what type(s):

Credit/Debit Card Data Intellectual Property of Others Medical Information/Health Records Employee/HR Information Bank Accounts and Records General Customer Information (emails, user IDs, passwords)

Social Security Numbers Children’s Information (subject to COPPA) Other:

43. What is the maximum number of unique individuals for whom you collect, store or process any amount of confidential information (annually)?

< 100,000 100,001 – 250,000 250,001 – 500,000 500,001 – 1,000,000 1,000,001 – 2,500,000 2,500,001 – 5,000,000 > 5,000,000

44. Do you outsource any of the following?a. Web Hosting/Data Center Operations................................................................................................. Yes Nob. Data/Transaction Processing............................................................................................................... Yes Noc. Network Security ................................................................................................................................. Yes Nod. Customer Service................................................................................................................................ Yes NoList all IT or outsource providers, along with the service that such providers provide for you, in Additional Information section at the end of this application.

45. Do your contracts with your IT service providers or outsource providers for the above services address the following:a. Provide you with indemnification for provider misconduct, errors, omissions and negligence?........... Yes Nob. Identify the provider’s responsibilities for safeguarding customer and confidential information?......... Yes Noc. Identify the security measures that the provider will provide or follow?............................................... Yes No

46. Do you have formal procedures for reviewing IT or outsource providers’ security practices?.................... Yes No

INFORMATION SECURITY PROGRAM47. Who is responsible for information security within your organization? Name and Title

48. Do you have a comprehensive written information security program?....................................................... Yes No

49. Do you have written procedures governing how you make changes to your information securitycomponents or programs?......................................................................................................................... Yes No

50. Do you have a company policy or procedure for secure care, handling and storage of private, sensitive or confidential information on portable communication devices (e.g., laptops, tablets or smartphones)?. . Yes No

51. Is remote access for portable communication devices restricted to Virtual Private Networks (VPNs)?...... Yes No

52. Do you have a written privacy policy?........................................................................................................ Yes NoIf yes: a. Does it specify the specific data you may collect and how you or others may use data?....... Yes No

b. Does it identify if you share or sell any user/customer data with other parties?...................... Yes Noc. Does it specify how your users/customers can opt in or opt out regarding privacy?............... Yes No


d. Does it specify how your user/customer information is secured?............................................ Yes Noe. Is it publicly available on your website? ................................................................................. Yes Nof. How often do you review and update your privacy policy?....... Annually Bi-Annually

.....................................................................................................................................................................g. How often do you perform audits to ensure compliance? ........ Annually Bi-Annually

.....................................................................................................................................................................

53. If applicable, are you currently compliant with the Payment Card Industry Data Security Standard (PCI-DSS)? ................................................................................................................... Yes No N/Aa. If yes, what is the total number of annual credit card transactions? b. If yes, how many Merchant Service Agreements are you subject to?

54. If applicable, are you currently HIPAA compliant?........................................................................ Yes No N/A

55. If you answered yes to question 53 or 54, have you successfully completed an annual cycle of compliance for each framework?.................................................................................................. Yes No N/A

56. Is user-specific, private, sensitive or confidential information stored on your servers encrypted?.............. Yes Noa. If yes, is data at rest encrypted?......................................................................................................... Yes Nob. If yes, is data in transit encrypted?...................................................................................................... Yes No

57. Is the responsibility for the secure care, handling and storage of private, sensitive or confidentialinformation of others addressed in your contracts with your customers?................................................... Yes No

58. Is the responsibility for the secure care, handling, and storage of private, sensitive or confidentialinformation of others addressed in your contracts with your subcontractors, independentcontractors or third party vendors who may have access to or use of this information?............................. Yes Noa. If yes, does this include that third party vendors are responsible for end of lifecycle document

destruction?......................................................................................................................................... Yes Nob. If yes, does this include third party custodians such as housekeeping or maintenance or others

who may regularly have access to your premises?............................................................................. Yes No

59. Do you have a data segmentation program that separates data by sensitivity levels?.............................. Yes NoIf yes, for which of the following do you have varying protections based on the level of sensitivity of data?

Access Control (e.g., Two Factor Authentication)Data Handling and Retention

Data DestructionEncryption Other:

60. Do you run anti-virus software across all components of your network?.................................................... Yes No

61. Do you maintain network logs and generate exception reports to monitor:a. Unacceptable or restricted transactions?............................................................................................. Yes Nob. Correcting or reversing entries?........................................................................................................... Yes Noc. Unsuccessful attempts to access restricted information on the site?................................................... Yes No

62. Identify who provides or maintains the following safeguards:a. Intrusion detection software............................................................................................. You Vendor N/Ab. Vulnerability or penetration testing.................................................................................. You Vendor N/Ac. Backup and recovery processes...................................................................................... You Vendor N/A

63. Do you have a process in place to ensure all antivirus protection, software updates/patchesand equipment security settings are properly installed in a timely manner?............................................... Yes No

64. Do you have regular policies and procedures for identifying computer system vulnerabilities and obtaining remedial software patches?........................................................................................................ Yes No

65. Do you have a firewall installed and configured (hardened) to protect your network?............................... Yes NoIf yes, is there a firewall administrator accountable for maintaining this firewall?....................................... Yes No

66. Do you have an outside party conduct an audit of your internal network or computer systems?................ Yes NoIf yes, have all recommendations been implemented?............................................................................... Yes NoIf not all recommendations have been implemented, explain which recommendations are not yet implemented in Additional Information section of this application.

67. Do you have a written policy for document retention along with end of lifecycle destruction that includespaper and electronic records?.................................................................................................................... Yes NoIf yes, do you use a third party vendor?..................................................................................................... Yes No

68. With respect to computer systems, do you have: (select all that apply) Secondary/backup computer system Business Continuity Plan Disaster Recovery Plan


Incident Response plan for network intrusions and virus incidentsIf yes to any of the above, how often are such plans tested? If a secondary / backup system is in place, how long before this system becomes operational?

If you have a Business Continuity Plan for your computer systems, does your plan address a disruptionto an IT provider or an outsource provider?............................................................................................. Yes No

COMMUNICATIONS AND MEDIA LIABILITY

Communications And Media Liability Coverage is not requested. (If this box is checked, skip this section. Move to page 9.)

69. Provide information about your current insurance for Communications or Media Liability (if any):

Policy Period(mm/dd/yyyy-mm/dd/yyyy)

Insurance Company


(mm/dd/yyyy)

Premium

$ $ $

70. Within the past five years, have any of the coverages been declined, cancelled or not renewed?............ Yes No(Not applicable in Missouri) If yes, attach detailed explanation or describe in Additional Information section at the end of this application.

71. Do your business activities include, or your website contain, disseminate, or allow, the following? (check all that apply): Publishing of original works Music or video downloads, including peer to peer (P2P) file sharing Publishing or dissemination of third-party user-generated content

72. Does your intellectual property clearance policy include any of the following?a. A comprehensive written program in place for managing intellectual property rights …………........... Yes Nob. Legal review of all content prior to release or dissemination, including software code........................ Yes Noc. Intellectual property searches by outside law firm............................................................................... Yes Nod. Intellectual property searches by internal legal department................................................................. Yes Noe. Acquisition of all necessary rights, licenses or consents of content used by or created by you........... Yes Nof. Acquisition of all necessary rights, licenses or consents of content owned by or provided

by third parties..................................................................................................................................... Yes Nog. Internal audit of each operating department to ensure that intellectual property rights are

being properly secured and your established procedures are being followed...................................... Yes Noh. Agreements with outside developers or consultants include provisions granting you ownership

of the intellectual property rights and business methods incorporated into any work for hireperformed for you or on your behalf..................................................................................................... Yes No

i. Require employees and “work for hire” contractors to sign a statement that they will not use previous employers’ or clients’ trade secrets or other intellectual property.......................................... Yes No

j. Obtaining written permission of any website you link to or frame........................................................ Yes Nok. Formal procedure for handling complaints of infringement.................................................................. Yes Nol. Formal training for employees regarding your policies for managing intellectual property................... Yes No

73. Do you use the material of others (e.g., text, video, graphics, photos or music) in your websitesor in other material printed, broadcast, published or distributed by you or by someone on yourbehalf?....................................................................................................................................................... Yes No

74. Do you hire outside website developers or consultants to provide work for you or on your behalfincluding development of content?............................................................................................................. Yes NoIf yes, do your agreements with the outside developers or consultants include provisions grantingyou ownership of the intellectual property rights and business methods incorporated into any workfor hire performed for you or on your behalf?............................................................................................. Yes No

75. Do you have a formal procedure for editing or removing controversial, offensive or infringingmaterial from material distributed, broadcast or published by you or someone on your behalf?................ Yes No

76. Have you received notification that any of your materials, products or services infringe on theintellectual property rights of another party?.............................................................................................. Yes NoIf yes, provide details in Additional Information section at the end of this application.


77. Do you have a formal procedure for responding to allegations that content created, displayed or published is libelous, infringing or in violation of a third party’s privacy rights?...................................... Yes NoIf yes, is your procedure reviewed by a qualified attorney?........................................................................ Yes No

78. Do you use any software code that is licensed from a third party or outsource provider? ......................... Yes No

FIRST PARTY EXPENSE REIMBURSEMENT First Party Expense Reimbursement Coverage is not requested. (If this box is checked, skip this section.)

79. Do you have a written data breach response plan in place?...................................................................... Yes No

80. Has your company contracted with outside vendors (e.g., forensics, legal services, public relations) and pre-arranged services to assist in the event that you would need to execute your data breach response plan? .......................................................................................................................................... Yes No

81. Do you have an alternate means of transacting business in the event of a network or website outage?. . Yes No

82. Within the last five years have you experienced a network or website outage as a result of a computer system disruption?..................................................................................................................... Yes No

83. Have you ever been the subject of a ransomware attack?......................................................................... Yes NoIf yes, explain in Additional Information section at the end of this application.

84. Have you ever been the subject of any other type of cyber extortion attack?............................................ Yes NoIf yes, explain in Additional Information section at the end of this application.

85. Is dual authorization required for all wire transfers?................................................................................... Yes No86. What is the average daily dollar volume of electronic funds transfers? $

87. Are transfer verifications sent to an employee/department other than the one who initiatedthe transfer?............................................................................................................................................... Yes No

88. Have you discovered any telecommunications theft or been contacted by any long distance carrier regarding possible abuse of your telecommunications system within the past five years?........................ Yes No

89. Does each location or system have the Call Detail Recording (CDR) feature?.......................................... Yes NoIf yes, how often is this information reviewed?

LOSS INFORMATIONIf the answer to any of the questions below is yes, provide details in Additional Information section of this application.90. Have you ever received any complaint concerning the products or services provided by you or

independent contractors working on your behalf?...................................................................................... Yes No

91. Within the past five years, have you sued any customers for non-payment of fees?................................. Yes No

92. Within the past five years, have you sustained any network intrusion, virus attack, hackingincident, data theft or similar event?........................................................................................................... Yes No

93. Within the past five years, have you notified customers or employees that their private, sensitive or confidential information may have been compromised?............................................................................. Yes No

94. Within the past five years, have you received any notification that any of your material, content, products or services infringe on the intellectual property rights of another party?...................................... Yes No

95. Does any described authorized person* in your organization have any knowledge or informationof any fact, circumstance, or incident that has resulted in a dispute or claim or may reasonably beexpected to result in a claim against you or your subsidiaries?.................................................................. Yes No

*Described authorized person means any person while he or she is: Your director, board member or executive officer; Your risk manager, or any leader of your legal, finance, risk management or other department that is

responsible for insurance matters; or Your appointed or elected official (if you are a public entity).


REQUIRED ATTACHMENTS

Attach a copy of each of the following documents: Your standard contracts and licensing agreements. Your most recent audited or annual financial statements. Your loss runs for the past five years (Not required for any policy period in which we provided this insurance.)

For information about how Travelers compensates independent agents, brokers, or other insurance producers, please visit this website:

If you prefer, you can call the following toll-free number: 1-866-904-8348. Or you can write to us at Travelers, Enterprise Development, One Tower Square, Hartford, CT 06183.

This application, including any material submitted in conjunction with this application or any renewal, does not amend the provisions or coverages of any insurance policy or bond issued by Travelers. It is not a representation that coverage does or does not exist for any particular claim or loss under any such policy or bond. Coverage depends on the facts and circumstances involved in the claim or loss, all applicable policy or bond provisions, and any applicable law. Availability of coverage referenced in this document can depend on underwriting qualifications and state regulations.

FRAUD STATEMENTS – ATTENTION APPLICANTS IN THE FOLLOWING JURISDICTIONS

ALABAMA, ARKANSAS, DISTRICT OF COLUMBIA, MARYLAND, NEW MEXICO, AND RHODE ISLAND: 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 and confinement in prison.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.FLORIDA: 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 of the third degree.KANSAS: 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 insurance 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 commits a fraudulent insurance act. KENTUCKY, NEW JERSEY, NEW YORK, OHIO, AND 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. (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.)LOUISIANA, 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 include imprisonment, fines, and denial of insurance benefits.OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

SIGNATURES

Producer information only required in Florida, Iowa, and New Hampshire.

Authorized Representative Signature*:x

Authorized Representative Name – Printed:

Date (mm/dd/yyyy):

Producer Signature*:x

State Producer License No (required in FL):

Date (mm/dd/yyyy):

Agency: Agency Contact: Agency Phone Number:


* If you are electronically submitting this document, apply your electronic signature to this form by checking the Electronic Signature and Acceptance box below. By doing so, you agree that your use of a key pad, mouse, or other device to check the Electronic Signature and Acceptance box constitutes your signature, acceptance, and agreement as if actually signed by you in writing and has the same force and effect as a signature affixed by hand.

Electronic Signature and Acceptance – Authorized Representative Electronic Signature and Acceptance – Producer

ADDITIONAL INFORMATION

This area may be used to provide additional information to any question. Attach additional pages if needed. Please reference the question number.


Documents

Claims made disclosure - The Travelers Companies€¦ · Web viewLIABILITY COVERAGE APPLIES ON A CLAIMS-MADE BASIS. ... Evaluation of all outstanding contracts or service agreements