Information & Professional Risk Playbook SM (iprp) Application

Transcription

1 Information & Professional Risk Playbook SM (iprp) Application THIS IS AN APPLICATION FOR ONE OR MORE COVERAGE SECTION(S) OF A POLICY. EACH COVERAGE SECTION IS WRITTEN ON A CLAIMS-MADE BASIS AND COVERS ONLY CLAIMS FIRST MADE AGAINST THE INSURED(S) DURING THE POLICY PERIOD OR THE EXTENDED REPORTING PERIOD, IF EXERCISED. THE WRITTEN STATEMENTS AND REPRESENTATIONS MADE IN THIS APPLICATION AND ANY MATERIALS OR INFORMATION SUBMITTED WITH THIS APPLICATION ARE INCORPORATED INTO, AND WILL FORM THE BASIS OF, ANY POLICY OF INSURANCE ISSUED BY THE INSURER. IF A POLICY IS ISSUED, COVERED DEFENSE COSTS AND OTHER EXPENSES WILL REDUCE THE POLICY S LIMIT OF LIABILITY AND, EXCEPT AS OTHERWISE SPECIFIED IN ANY SPECIFIC COVERAGE SECTION, WILL BE SUBJECT TO THE POLICY S RETENTION PROVISIONS. BOLD- FACED TERMS WITHIN THIS APPLICATION THAT ARE DEFINED IN THE POLICY FOR WHICH THIS IS THE APPLICATION SHALL HAVE THE SAME MEANING IN THIS APPLICATION. A. GENERAL INFORMATION 1. Name of Applicant: Address: Suite/Floor: City: State: Zip Code: Website: Date Established: 2. Have you completed any mergers or acquisitions in the last three years? Yes No If yes, please provide details. 3. Please provided a brief description of your business (industry, how you earn income, etc.): CS EO 9004 CL (6 12) Page 1 of 15

2 B. COVERAGES Select each coverage requested and indicate the limits and deductible preferences for each: Coverages CURRENT PROGRAM REQUESTED PROGRAM Retroactive Limit Deductible Liability Coverages Date Limit Deductible Professional Services Liability $ $ $ $ Privacy Breach Liability $ $ $ $ Privacy Regulatory Liability $ $ $ $ Security Liability $ $ $ $ Media Liability $ $ $ $ First Party Retroactive Limit Deductible Coverages Date Limit Deductible Breach Notification Expenses $ $ $ $ Breach Mitigation Expenses $ $ $ $ Crisis Management Expenses $ $ $ $ Loss of Business Income and Extra $ hrs $ hrs Expenses Data Restoration Expenses $ $ $ $ Theft of Money or Securities by Others $ $ $ $ Network Extortion Expenses $ $ $ $ Policy Aggregate C. OPERATIONS & FINANCIALS $ Please provide the following information. # of Employees $ $ Prior 12 months Current 12 months Next 12 months U.S. Total Gross Revenues $ $ $ Foreign Total Gross Revenues $ $ $ Total Gross Revenues $ $ $ Net Income $ $ $ Percentage Revenues from Online Commerce % % % Please attach copy of most recent, audited financial statements for firms requesting business income coverage, firms with revenues > $50 million or firms requesting deductibles greater than $50,000. CS EO 9004 CL (6 12) Page 2 of 15

3 D. PROFESSIONAL SERVICES COVERAGE SECTION Check Here if Not Applying for this Coverage and Proceed to the Privacy and Security Coverage Section a. Products And Services Please describe your major products and services including the estimated percentage of current year revenues derived from each Product or Service Percentage of Revenue % % % % % % Typical Customers (business or consumer, industries, etc.) b. Largest Clients/Projects Please provide details on your five largest clients or projects Name of Client Description of Services Gross Receipts Length of Contract $ $ $ $ $ c. Client Relationships 1. What percentages of your revenues for products or services are purchased or provided under the following types of agreements: Your Standard Contract Wording (including Terms of Service / End User License Agreement) Client Contract Wording Purchase Order None % % % % 2. Please identify which of the following provisions are included in your standard contract wording: Provision Hold Harmless Indemnification Limitation of Liability Ownership of Intellectual Property Disclaimer of Warranties In Favor of Applicant In Favor of Client Mutually Beneficial CS EO 9004 CL (6 12) Page 3 of 15

4 3. How do you manage the review and approval of client contract wording or modifications to your contract wording? 4. If you provide software, hardware or information services, which of the following risk management practices do you employ: Practice Secure Coding Practices (please provide details) Developer Testing Beta Testing User Acceptance Testing Client Sign Off on Specifications Client Sign Off at Project Milestones Client Sign Off on Final Delivery Escalation Process for Client Complaints 5. How many times have you sued a client for fees in the last 5 years? d. Sub-Contractors 1. Please describe the situations in which you use independent contractors or sub-contractors to provide your professional services (e.g. specific services, coverage of certain territories, etc.)? 2. Approximately what percentage of your revenue is derived from the services provided by these contractors? % 3. Please check which of these provisions are contained in your contracts with independent or subcontractors: a. Indemnification/hold harmless for their work product: b. Ownership of Intellectual Property rights c. Professional liability insurance requirement of at least $ in limits. CS EO 9004 CL (6 12) Page 4 of 15

5 E. FIRST AND THIRD PARTY PRIVACY AND SECURITY COVERAGE SECTION Check Here if Not Applying for these Coverages and Proceed to the Media Liability Coverage Section a. Records/Data Exposure Please indicate the maximum volume of the following types of confidential information (including employee data) in process, stored or transmitted at any one time on: Types of Records Stored/Type of Storage Total (All Computer Networks, Devices & Non-Electronic Storage) Any Single Encrypted Back-Up Tape, Flash Drive, Laptop, Smart Phone, Tablet or Mobile Device Any Single Un- Encrypted Back-Up Tape, Flash Drive, Laptop, Smart Phone, Tablet or Mobile Device Non- Electronic Storage (Paper/Film Records) Social Security Numbers Credit/Debit Account Numbers Bank/Brokerage Account Numbers Medical Records/Protected Health Information Drivers License Numbers Other (please specify) Total b. Technical Security Please indicate how you manage the following security controls: Control Password Security: Unique for each user? Strong? Frequency of required changes? How Employed Anti-Virus/Anti-Spyware Software: On desktops? On Servers? Scanning attachments? On mobile devices? CS EO 9004 CL (6 12) Page 5 of 15

6 Encryption of data:: Back-up tapes? Flash drives? Laptops? Smart Phones & Tablets? Databases? Encryption of Wireless Networks: WEP WPA/WPA2 Guest network separated from servers with sensitive data (only if no wireless networks are used) Software Patching: Subscribe to auto notice from vendors where offered? Time standard for Installing critical/security related patches? Remote Access Security: VPN? Two-Factor Authentification? Other (please specify)? Intrusion Detection & Prevention Software/Service Data Loss Prevention/Egress Filtering Hardening of Servers Against Known Attack Methods (e.g. SQL Injection, etc.) Data Back Up: Frequency? Segregation from Production Environment? c. Access Privileges 1. What types of pre-employment screening do you perform on employees with access to confidential information (background checks, credit checks, drug screening, etc.)? 2. Do you limit individual user s access privileges to only those necessary to carry out their duties as your employees or contractors? Yes No 3. Do you have a process in place to delete systems access within 24 hours of the termination of employment or vendor contracts? Yes No CS EO 9004 CL (6 12) Page 6 of 15

7 If not, please explain your process for deleting access for terminated employees and vendors: d. Physical Security/Non-Digital Records 1. Please describe how you limit access to: a. Server rooms: b. Works areas where sensitive information is used or stored? c. File rooms/storage areas with microfilm or other non-digital records containing sensitive information? 2. Do you have a process to ensure that paper records containing sensitive information are shredded prior to disposal? Yes No 3. What methods do you employ to you ensure that all sensitive data from the hard drives of desk tops, servers, copiers, fax machines and other devices are permanently deleted before these devices are donated, sold or otherwise disposed of? e. Policies & Culture 1. Do you have a designated information security or privacy officer? Yes No If not, who is responsible and accountable for your organization s information security and privacy? 2. Do you have the ability to identify what sensitive data is stored on individual servers, storage media, mobile devices, etc? Yes No 3. Which of the following do you have in place: Records Retention Internal Policy Established/Last Modified on: Most Recent Reinforcement Activity Example 6/1/11 Video Posted to Intranet 5/5/12 Privacy Acceptable Use Network Security CS EO 9004 CL (6 12) Page 7 of 15

8 HIPAA Policy to Comply with Standards Established/Last Modified on: Most Recent Audit/Certification ISO series (please indicate which parts in response) PCI DSS Plan Established/Last Modified on: Most Recent Simulation/Dry Run Disaster Recovery Breach Response 4. Do you audit data access by authorized users: a. When you see anomalies in access patterns? Yes No b. In response to complaints or suspected breaches? Yes No c. As part of regular internal and/or regulatory compliance processes? Yes No f. Data Collection And Dissemination 1. Do you collect any of the following information from individuals (check all that apply): a. User Location (Geo Tagging, etc.)? Yes No b. Web browsing history? Yes No c. Online purchase history? Yes No d. Personal account credentials (e.g., requiring job applicants to provide Facebook ID and passwords, etc.)? Yes No 2. What methods do you use to collect individually identifiable information: a. Self reporting by customers, patients or site visitors? b. HTML Cookies? c. Flash Local Storage (aka Flash Cookies )? d. Adware/Spyware? e. Mobile or Social Media Apps? f. Other (please specify)? 3. Do you sell this information to, or share it with any third parties? Yes No If yes, do you generate income from this activity? Yes No 4. What methods do you employ to disclose your data collections and dissemination practices to those from who you collect data? How do you document the individual s agreement with this use of their data? CS EO 9004 CL (6 12) Page 8 of 15

9 5. If you collect data from users of mobile or social media applications, do you have a process in place to comply with network/site developer policies re acceptable collection and dissemination of user data? g. Vendors 1. Do you use third parties to collect process, store or destroy sensitive information on your behalf? (if not, please proceed to the Business Continuity questions below). Yes No 2. Please list you major vendors for any of the following services if performed by a third party: Service Data Back Up/Archiving Web Hosting Cloud Based Software & Services Electronic Payments Payroll/Employee Benefits Non-Digital Records Retention Document/Data Destruction Vendor(s) 3. What due diligence do you perform on vendors who hold private information on your behalf? 4. Do you require vendors to indemnify you for breaches of confidential data they hold on your behalf? Yes No If yes, what (if any) insurance limits do you require that they carry to address these exposures? F. MEDIA LIABILITY 1. Please describe the types of content you create or disseminate: Type of Content On Your Behalf On Behalf of Third Parties Your Web Site Your Blogs Your Social Media Presence Software/Software as a Service Computer/Video Games CS EO 9004 CL (6 12) Page 9 of 15

10 Social Networking/Social Media Functions for Outside Users Mobile/Social Media Apps Music or Video File Streaming Music or Video Peer to Peer File Sharing Ad Content/Web Sites Created for Others Web Site Hosting Hosting User Posted Content Electronic or Paper Publications Advice/How To Information Classified Ads 2. Do you have an editorial or legal review process in place to ensure that you are not disseminating confidential, defamatory or infringing content? Yes No 3. Do you disseminate any content, which includes material supplied by customers, contractors or vendors? Yes No If yes, check all that apply: a. Require the third party to hold you harmless for any defamatory or infringing content supplied to you? b. Obtain all necessary licenses for this content? c. Have a process in place to monitor compliance licenses for third party content (including Open Source software licenses)? 4. Do you host third party content on your web site(s)? Yes No If yes, do you have policies in place (take down protocols, etc.) to comply with the safer harbor provisions of the Digital Millennium Copyright Act and the Communications Decency Act? Yes No 5. Do you require employees and contractors to affirm in writing that they will not use content created for prior employers or customers in content created on your behalf? Yes No 6. Do you have a social media policy for employees and contractors acting on your behalf that addresses: a. Maintaining customer/patient confidentiality? Yes No b. Personal posts related to your business? Yes No c. Infringement of Third Party Intellectual Property rights? Yes No CS EO 9004 CL (6 12) Page 10 of 15

11 d. Defamation of competitors, others? Yes No e. Comments/claims regarding your business, product or services? Yes No G. CLAIMS EXPERIENCE AND POTENTIAL EXPOSURES 1. In the past three years has any person or entity proposed for insurance been a party to any: a. Civil or criminal action or administrative or regulatory proceeding relating to such person or entity s eligibility or fitness to be licensed to perform Professional Services or alleging any Wrongful Act in providing or failing to provide Professional Services? Yes No b. Any other criminal action? Yes No c. Civil or criminal action or administrative or regulatory proceeding relating the any actual or alleged infringement of the rights of privacy, publicity, copyright or trademark or any defamation of another party or alleging any Media Offense? Yes No 2. In the past five years has any person or entity proposed for insurance: a. Experienced a Privacy Breach, Security Event, security or confidentiality breach involving any computer networks, electronic or non-electronic data storage, or data entrusted to a third party vendor? Yes No b. Notified any individuals about any actual or potential Privacy Breach? Yes No c. Been subject to a regulatory investigation and/or to regulatory penalties as a result of an actual or alleged Privacy Breach? Yes No d. Been subject to a civil, criminal or administrative proceeding or demand alleging an actual or alleged Privacy Breach? Yes No e. Incurred Data Restoration Expenses as a result of a Security Event? Yes No f. Suffered a loss of Business Income as a result of a Security Event? Yes No g. Suffered a Theft Loss as a result of a Security Event? Yes No h. Incurred Network Extortion Expenses or otherwise been the subject of an extortion attempt involving an actual or threatened Privacy Breach, or Security Event? Yes No 3. Does any person or entity proposed for insurance have knowledge or information of any actual or alleged fact or circumstance or Wrongful Act, Privacy Breach, Security Event, Media Offense or extortion attempt, which may reasonably be expected to give rise to a Claim or First Party Event against, or inquiry or investigation of, any such person or entity? Yes No If the response is Yes to any part of questions a, b or c above, please provide details. It is understood and agreed that, without limiting any rights of the Insurer, if any litigation, action, proceeding, suit, knowledge or information exists in response to any part of questions a, b or c above, any Claim or First Party Event arising therefrom shall be excluded from this proposed coverage. CS EO 9004 CL (6 12) Page 11 of 15

12 H. REPRESENTATIONS The undersigned authorized officer of the Proposed Policyholder declares on behalf of the Proposed Policyholder and all persons and entities proposed for insurance that the statements set forth in this Application, including any supplemental application section for any particular Coverage Section, are true. It is understood that the accurateness and completeness of the statements in this Application, including material submitted to the Insurer, are relied upon by the Insurer, and shall be the basis of the policy of insurance, if issued, and shall be deemed incorporated herein. The undersigned officer of the Proposed Policyholder agrees that if the information supplied on this Application changes between the date of this Application and the effective date of the insurance that he/she will immediately notify the Insurer of such changes, and the Insurer may withdraw or modify any outstanding quotations or authorizations or agreements to bind the insurance. Signing this Application does not bind the applicant or the Insurer to issue an insurance policy, but it is agreed that this Application shall be the basis of the contract should a policy be issued, and it will be attached to and become part of the Policy. FRAUD PREVENTION WARNINGS NOTICE: ANY PERSON WHO KNOWINGLY, OR KNOWINGLY ASSISTS ANOTHER, FILES AN APPLICATION FOR INSURANCE OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD AN INSURANCE COMPANY MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO CRIMINAL AND CIVIL PENALTIES AND LOSS OF INSURANCE BENEFITS. NOTICE TO ARKANSAS APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO COLORADO APPLICANTS: 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 FOR INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT. NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY FILES A STATEMENT OF CLAIM OR APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. NOTICE TO HAWAII APPLICANTS: FOR YOUR PROTECTION, HAWAII LAW REQUIRES YOU TO BE INFORMED THAT PRESENTING A FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT IS A CRIME PUNISHABLE BY FINES OR IMPRISONMENT, OR BOTH. CS EO 9004 CL (6 12) Page 12 of 15

13 NOTICE TO KENTUCKY APPLICANTS: 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. NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO MAINE APPLICANTS: 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. NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY AND WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY AND WILLFULLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES. NOTICE TO NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES. NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD KNOWINGLY THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. NOTICE TO OREGON APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS A APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD. NOTICE TO PENNSYLVANIA APPLICANTS: 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 FACT MATERIALLY FALSE INFORMATION OR CONCEAL 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. NOTICE TO PUERTO RICO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH THE INTENTION TO DEFRAUD INCLUDES FALSE INFORMATION IN AN APPLICATION FOR INSURANCE OR FILE, ASSIST OR ABET IN THE FILING OF A FRAUDULENT CLAIM TO OBTAIN PAYMENT OF A LOSS OR OTHER BENEFIT, OR FILES MORE THAN ONE CLAIM FOR THE SAME LOSS OR DAMAGE, COMMITS A FELONY AND IF FOUND GUILTY SHALL BE PUNISHED FOR EACH VIOLATION WITH A FINE OF NO LESS THAN FIVE THOUSANDS DOLLARS ($5,000), NOT TO EXCEED TEN THOUSANDS DOLLARS ($10,000); OR IMPRISONED FOR A FIXED TERM OF THREE (3) YEARS, OR BOTH. IF AGGRAVATING CIRCUMSTANCES EXIST, THE FIXED JAIL TERM MAY BE INCREASED TO A MAXIMUM CS EO 9004 CL (6 12) Page 13 of 15

14 OF FIVE (5) YEARS; AND IF MITIGATING CIRCUMSTANCES ARE PRESENT, THE JAIL TERM MAY BE REDUCED TO A MINIMUM OF TWO (2) YEARS. NOTICE TO TENNESSEE APPLICANTS: 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. NOTICE TO TEXAS APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON. NOTICE TO VIRGINIA APPLICANTS: 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. NOTICE TO WASHINGTON APPLICANTS: 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. NOTICE TO WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON. NOTICE TO NEW YORK APPLICANTS: 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 ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. SIGNED: DATE: PRINTED NAME: TITLE: NOTE: If this Application is completed in Florida, please provide the Insurance Agent s name and license number as designated. If this Application is completed in Iowa, please provide the Insurance Agent s name only. If this Application is completed in New Hampshire, please provide the Insurance Agent s signature. PRODUCER (Insurance Agent or Broker) INSURANCE AGENCY OR BROKERAGE INSURANCE AGENCY TAXPAYER I.D. OR SOCIAL SECURITY NO. AGENT OR BROKER LICENSE NO. ADDRESS OF AGENT OR BROKER (Include Street, City and Zip Code) CS EO 9004 CL (6 12) Page 14 of 15

15 ADDRESS OF AGENT OR BROKER SUBMITTED BY (Insurance Agency) INSURANCE AGENCY TAXPAYER I.D. OR SOCIAL SECURITY NO. ADDRESS OF AGENT OR BROKER (Include Street, City and Zip Code) CS EO 9004 CL (6 12) Page 15 of 15