Claims made disclosure
|[pic] |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 INFORMATION
1. 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 No
If 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 No
b. Evaluation of all outstanding contracts or service agreements that will be included as part
of transaction Yes No
c. 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 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 |Projected |
| |Of Revenue |Activity Within|
| | |One Year |
|Information 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 INFORMATION
6. 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 |Requested Each Wrongful Act |Requested Retention |
| | |Date |Limit | |
|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 |Requested Retention or |
| | |Insurance |Waiting Period |
|Security Breach Notification And Remediation Expenses | Yes |$ |$ |
|Crisis Management Service Expenses | Yes |$ |$ |
|Business Interruption And Extra Expenses | Yes |$ | Hours |
|IT 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 No
If 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 is
part 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 No
TECHNOLOGY ERRORS AND OMISSIONS LIABILITY
14. Please provide information about your current insurance for Errors and Omissions Liability Coverages (if any):
|Policy Period |Insurance Company |Limit |Retention |Retroactive Date |Premium |
|(mm/dd/yyyy-mm/dd/yyyy) | | | |(mm/dd/yyyy) | |
| | |$ |$ | |$ |
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):
| Automotive | Healthcare/Medical |
|Aviation/Aircraft/Aerospace |Industrial/Factory Automation |
|Education |Media/Advertising |
|Emergency Services (e.g., 911, fire) |Professional Services (e.g., legal, accounting, medical or other services |
|Energy/Utilities |provided by licensed professionals) |
|Entertainment/Gaming |Retail |
|Financial Services (including banking, insurance or investment services) |Technology Companies |
|Government (for military or defense application) |Telecommunication Companies |
|Government (for non-military application) |Other: |
17. Have any of your products, services or operations been discontinued or recalled within the last five
years? Yes No
If 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 PROCEDURES
19. 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 No
If 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 No
b. Conditions of Customer Acceptance of Product or Service Yes No
c. Customer Maintenance Provision Yes No
d. Disclaimer of Warranties Yes No
e. Exclusive Remedy Yes No
f. Force Majeure Yes No
g. Integration Clause Yes No
h. Limitation of Liabilities Yes No
i. Limitation of Liabilities for Consequential Damages Yes No
j. 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 liability
for consequential damages? Yes No
If 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 provision
for liquidated damages? Yes No
26. Do you enter into contracts or service agreements that include a fixed time frame for completion of
all 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 |Length |Average Amount |Service Provided |
|(Type or Name) |(Average # of Months) | | |
| | |$ | |
| | |$ | |
| | |$ | |
PRODUCT DEVELOPMENT/QUALITY CONTROL
31. 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 No
b. Beta testing Yes No
c. Pre-Release testing for malicious code or other security flaws Yes No
d. Vendor certification process Yes No
e. Prototype development guidelines Yes No
f. 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 No
If 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 No
If 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 No
If 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 fixes
that 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 No
If 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 project
delays or past due contract issues with any customer? Yes No
If 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 |Insurance Company |Limit |Retention |Retroactive Date |Premium |
|(mm/dd/yyyy-mm/dd/yyyy) | | | |(mm/dd/yyyy) | |
| | |$ |$ | |$ |
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 No
If 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 No
b. Data/Transaction Processing Yes No
c. Network Security Yes No
d. Customer Service Yes No
List 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 No
b. Identify the provider’s responsibilities for safeguarding customer and confidential information? Yes No
c. 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 PROGRAM
47. 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 security
components 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 No
If 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 No
c. 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 No
e. Is it publicly available on your website? Yes No
f. 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/A
a. 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 No
a. If yes, is data at rest encrypted? Yes No
b. If yes, is data in transit encrypted? Yes No
57. Is the responsibility for the secure care, handling and storage of private, sensitive or confidential
information 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 confidential
information of others addressed in your contracts with your subcontractors, independent
contractors or third party vendors who may have access to or use of this information? Yes No
a. If yes, does this include that third party vendors are responsible for end of lifecycle document
destruction? Yes No
b. 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 No
If 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 Destruction |
|Data Handling and Retention |Encryption 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 No
b. Correcting or reversing entries? Yes No
c. 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/A
b. Vulnerability or penetration testing You Vendor N/A
c. Backup and recovery processes You Vendor N/A
63. Do you have a process in place to ensure all antivirus protection, software updates/patches
and 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 No
If 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 No
If yes, have all recommendations been implemented? Yes No
If 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 includes
paper and electronic records? Yes No
If 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 incidents
|If 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 disruption
to 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 |Insurance Company |Limit |Retention |Retroactive Date |Premium |
|(mm/dd/yyyy-mm/dd/yyyy) | | | |(mm/dd/yyyy) | |
| | |$ |$ | |$ |
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 No
b. Legal review of all content prior to release or dissemination, including software code Yes No
c. Intellectual property searches by outside law firm Yes No
d. Intellectual property searches by internal legal department Yes No
e. Acquisition of all necessary rights, licenses or consents of content used by or created by you Yes No
f. Acquisition of all necessary rights, licenses or consents of content owned by or provided
by third parties Yes No
g. Internal audit of each operating department to ensure that intellectual property rights are
being properly secured and your established procedures are being followed Yes No
h. Agreements with outside developers or consultants include provisions granting you ownership
of the intellectual property rights and business methods incorporated into any work for hire
performed 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 No
k. Formal procedure for handling complaints of infringement Yes No
l. 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 websites
or in other material printed, broadcast, published or distributed by you or by someone on your
behalf? Yes No
74. Do you hire outside website developers or consultants to provide work for you or on your behalf
including development of content? Yes No
If yes, do your agreements with the outside developers or consultants include provisions granting
you ownership of the intellectual property rights and business methods incorporated into any work
for hire performed for you or on your behalf? Yes No
75. Do you have a formal procedure for editing or removing controversial, offensive or infringing
material 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 the
intellectual property rights of another party? Yes No
If 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 No
If 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 No
If 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 No
If yes, explain in Additional Information section at the end of this application.
85. Is dual authorization required for all wire transfers? Yes No
86. 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 initiated
the 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 No
If yes, how often is this information reviewed?
LOSS INFORMATION
If 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, hacking
incident, 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 information
of any fact, circumstance, or incident that has resulted in a dispute or claim or may reasonably be
expected 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*: |Authorized Representative Name – Printed: |Date (mm/dd/yyyy): |
|x | | |
|Producer Signature*: |State Producer License No (required in FL): |Date (mm/dd/yyyy): |
|x | | |
|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.
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