AFB TECHNOLOGY SERVICES, TECHNOLOGY PRODUCTS AND PROFESSIONAL LIABILITY INSURANCE POLICY

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1 Multimedia and Broadcaster s Professional Liability Insurance Application AFB TECHNOLOGY SERVICES, TECHNOLOGY PRODUCTS AND PROFESSIONAL LIABILITY INSURANCE POLICY NOTICE: COVERAGE IS PROVIDED ON AN OCCURRENCE BASIS WITH DEFENSE COSTS INCLUDED WITHIN THE LIMITS. AMOUNTS INCURRED AS DEFENSE COSTS SHALL REDUCE AND MAY EXHAUST THE APPLICABLE LIMITS OF LIABILITY AND ARE SUBJECT TO THE APPLICABLE RETENTIONS. PLEASE READ THIS APPLICATION CAREFULLY. THE INSURER IS NOT OBLIGATED TO PAY ANY LOSS, INCLUDING DEFENSE COSTS, AFTER THE LIMIT OF LIABILITY HAS BEEN EXHAUSTED BY PAYMENT OF LOSS. PLEASE READ THIS APPLICATION AND THE POLICY CAREFULLY. Please fully answer all questions and submit all requested information and supplemental forms. Terms appearing in bold face in this Application are defined in the Policy and have the same meaning in this Application as in the Policy. If you do not have a copy of the Policy, please request it from your agent or broker. 1. Applicant Name: Address: Telephone: Fax: State of Incorporation: Website URLs: 2. Coverage Requested: Limits of Liability Requested: Each Claim or Related Claims: $ Aggregate for all Claims: $ Retention requested for each Claim or Related Claims: $10,000 $25,000 $50,000 $100,000 Other Desired Term of Policy: One Year Two Year Three Year Additional Insured Requested under Contract: No Yes Legal Name and Relationship to Insured of Entities requesting Additional Insured Status: BUSMT of 8

2 3. Covered Media For all print publications please specify: Name of Publication: Frequency of Distribution: Average Circulation: Geographic Market/Territory: For all broadcast or cable stations please specify: Station Call Letters: Highest 60 second advertising rate: Geographic Market/Territory: Station Format: Please list or describe all other media communications or activities for which coverage is sought: Is any proposed Covered Media broadcast distributed in a foreign language? yes no Please indicate total annual revenues generated by all proposed Covered Media: Prior 12 month period: $ Current 12 month period: $ 4. Covered Media Content Source Percentage of original content created by the Applicant: % Percentage of content supplied by third parties (independent contractors, stringers, freelancers, etc.): % Percentage of third party pre-published content: % Percentage of content derived from news or feature syndications, or wire services: % For all content supplied by third parties, does the Applicant always use a contract that includes warranties and indemnification language in favor of the Applicant relative to the originality of such content? Yes No If No, please describe circumstances under which content is used without indemnification from the author of such content: Does the Applicant have a written policy with regard to receipt and acknowledgement of unsolicited material? Yes No BUSMT of 8

3 Does the Applicant have a written policy with regard to receipt and response to retraction requests? Yes No If the Applicant is involved in newsgathering, please confirm whether the following methods are used: Undercover Investigations Yes No Hidden Camera or Microphones Yes No Reliance Upon Anonymous Sources Yes No If yes to any of the above please attach a copy of the written policy governing the use of such techniques. Does the Applicant use a delay device for all live programming? Yes No If No, please describe under what circumstance a delay device would not be used: 5. Risk Management Procedures: Does the Applicant have an experienced Media attorney on retainer, or in-house counsel, review all content and internal controls/procedures? Yes No Name of Attorney: Years of Media Experience: Name of Firm: Location of Firm: If Legal Review is not provided by an attorney, please provide a detailed description of the prepublication/pre-broadcast review process: Have all Releases and Licenses been obtained relative to the content and individuals that are the subject of, or appearing or portrayed in, any of the proposed Covered Media? Yes No Have musical rights been cleared including: Recording and synchronization rights Yes No Performing rights Yes No Distribution rights for all forms contemplated Yes No If the answer to any of the above is no, please confirm whether these rights will be obtained prior to dissemination. Yes No If original music was commissioned, has a warranty of originality and an indemnity against third party claims been obtained by the composer? Yes No 6. Other Insurance Information: BUSMT of 8

4 Does the Applicant currently purchase media liability insurance? Yes No If yes, please provide: Name of Insurer: Policy Period: Continuously in force since: Policy Limit: Deductible: Premium: Claims Made or Occurrence: Does the Applicant currently maintain a comprehensive general liability policy? Yes No If yes, please provide: Name of Insurer: Policy Period: Policy Limit: Personal Injury Coverage Included: Yes No Product Liability Coverage included: Yes No MISSOURI APPLICANTS/AGENTS DO NOT ANSWER THE FOLLOWING THREE QUESTIONS. Has any liability insurance for the Applicant or this particular production(s) ever been declined or canceled? Yes No Have any of the Applicant s current media or professional liability insurers indicated intent not to offer renewal terms? Yes No If Yes, attach details. Has any media liability insurance ever been declined or cancelled? Yes No If Yes, please explain: 7. PRIOR CLAIMS AND LOSSES: During the past ten years, has the Applicant been sued or threatened with suit for any act, error, or omission relating to the gathering of information, including but not limited to libel, slander, any form of invasion of privacy or appropriation of name likeness, infringement of copyright or trademark, infliction of emotional distress, false arrest, wrongful entry, or trespass? Yes No If Yes, attach details. For Minnesota applicants only, please indicate if the Applicant has given written or oral notice under the provisions of any prior or current media liability policy of specific facts or circumstances which might give rise to a Claim being made against any proposed Insured? Yes No Have any Loss payments been made on behalf of any proposed Applicant under the provisions of any prior or current media liability policy or similar insurance? Yes No If Yes, attach details. Please indicate the number of subpoenas served upon the Applicant during the past five years seeking documents or information obtained in the course of newsgathering activities? Please indicate how many subpoenas the Applicant has challenged by filing a court motion. No Applicant, director, officer, employee or other proposed insured has knowledge or information of any fact, circumstance, situation, event or transaction which may give rise to a claim under the proposed insurance except as follows: BUSMT of 8

5 If no such knowledge or information, check here: None Attach the following materials regarding the Applicant: Copy of standard releases/license agreements Copy of standard contract used with third party content providers Copy of standard advertising agreements Resumes of principals if Applicant has been in business for less than three years THE UNDERSIGNED IS AUTHORIZED BY THE APPLICANT AND DECLARES THAT THE STATEMENTS SET FORTH HEREIN AND ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE TRUE. SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THE STATEMENTS CONTAINED IN THIS APPLICATION, ANY SUPPLEMENTAL APPLICATIONS, AND THE MATERIALS SUBMITTED HEREWITH ARE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED AND HAVE BEEN RELIED UPON BY THE INSURER IN ISSUING ANY POLICY. THIS APPLICATION AND MATERIALS SUBMITTED WITH IT SHALL BE RETAINED ON FILE WITH THE INSURER AND SHALL BE DEEMED ATTACHED TO AND BECOME PART OF THE POLICY IF ISSUED. FOR UTAH AND WISCONSIN RESIDENTS: SUCH APPLICATION AND MATERIALS SHALL BECOME PART OF THE POLICY PROVIDED THAT THEY ARE ATTACHED TO THE POLICY AT THE TIME OF ITS DELIVERY. THE INSURER IS AUTHORIZED TO MAKE ANY INVESTIGATION AND INQUIRY IN CONNECTION WITH THIS APPLICATION AS IT DEEMS NECESSARY. PROVIDED, THE APPLICANT AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, THE APPLICANT WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, 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. I HAVE READ THE FOREGOING APPLICATION FOR INSURANCE INCLUDING ATTACHMENT A AND REPRESENT THAT THE RESPONSES PROVIDED ON BEHALF OF THE APPLICANT ARE TRUE AND CORRECT. WARNING ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT (S)HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD. 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 BUSMT of 8

6 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. 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 INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY IN THE THIRD DEGREE. 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 CONFINMENT 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 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 OR KNOWING 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: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN BUSMT of 8

7 INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY. NOTICE TO OREGON 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 MAY BE GUILTY OF INSURANCE FRAUD WHICH MAY SUBJECT SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES, INCLUDING BUT NOT LIMITED TO FINES, DENIAL OF INSURANCE BENEFITS, CIVIL DAMAGES, CRIMINAL PROSECUTION AND CONFINEMENT IN STATE PRISONS. 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 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. NOTICE TO TENNESSEE, VIRGINIA AND 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 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 CLAIMS 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: Must be signed by corporate officer with authority to sign on Applicant s behalf Printed Name and Title Date: Day Month Year 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. BUSMT of 8

8 Name of Insurance Agent License Identification No. Authorized Representative If this Application is completed in Wisconsin, please note the following: If this Policy is cancelled by the Named Insured, the Insurer shall retain the customary short rate portion of the premium hereon. If this Policy is cancelled by the Insurer, the Insurer shall retain the pro rata portion of the premium hereon. Payment or tender of any unearned premium by the Insurer shall not be a condition precedent to the effectiveness of cancellation. BUSMT of 8

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