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Named Insured(s):ABC, IncAddress:123 Main St.Any Town, USAInsurance Carrier:Westport Insurance CorporationCoverage Provided:Errors & Omissions Policy Policy Number:ABC-EASY-AS-123Effective Dates: January 1, 2020 to January 1, 2021ABC, Inc’s Errors and Omissions policy is written on a “claims made” basis. A “claims made” policy responds to defend and/or pay or indemnify only those claims made or filed against the named insured and other insureds during the policy period, subject to all policy’s terms and conditions. Any “claim” or “potential claim” known to have been made or received during the policy period but not reported during the policy period or applicable extended reporting may result in severe coverage restrictions or the denial of coverage. ABC, Inc’s Errors and Omissions policy defines a “claim” to mean that: 1. an INSURED has received a summons, a subpoena, or any other notice of legal process; 2. an INSURED has received notice of any SUIT; or 3. an INSURED has received notice of a written demand, or a written demand for money or services. A “potential claim” is defined to mean that an INSURED has become aware of a proceeding, event, or development, which could in the future result in the institution of a CLAIM against an INSURED. Are you aware of or have you received notification of any “claim” or “potential claim” as defined in ABC, Inc’s Errors and Omissions for a “wrongful act” defined in the policy as: any negligent act, error, or omission of an INSURED in rendering PROFESSIONAL SERVICES or OTHER RELATED SERVICES for others; any PERSONAL INJURY or ADVERTISING INJURY in rendering PROFESSIONAL SERVICES or OTHER RELATED SERVICES for others; or any BREACH of PERSONAL DATA arising out of or in connection with the rendering of PROFESSIONAL SERVICES or OTHER RELATED SERVICES, but only if the INSURED has implemented current and commonly accepted technologies and methodologies designed to secure PERSONAL DATA and appropriate to the size and complexity of the agency and indecipherable to unauthorized individuals and which are in place at the time of the BREACH; provided, however, that any such technologies and methodologies must comply with privacy regulations found within the Health Insurance Portability and Accountability Act of 1996 or any other federal or state law or regulation, governing any industry in which the INSURED is rendering PROFESSIONAL SERVICES or OTHER RELATED SERVICES.YesNoIf “Yes,” the carrier must be notified. Please describe: ______________________________________________________________________________________________________________________________________________________________________________________________The undersigned attests that the above information is true to the best of their knowledge. The undersigned also attests that completion of this document does not replace nor negate the insured’s requirements to comply with all responsibilities and duties contained within the insurance policy referenced in this document. Signed: ____________________________________________________________________Print Name: ________________________________________________________________Position/Title: _______________________________________________________________Date: ______________________________________________________________________(Disclaimer: This is a sample using Westport Insurance policy language and an E&O policy. The language of each form and coverage type differs. This is intended only for an example.)NOTE 1: This polling letter must be completed and signed by:If a Corporation: All officers and directorsIf an LLC: All members and managersIf a partnership (LLP, GP or Other): All partnersIf a Sole Proprietor: The sole proprietor and any key managersNOTE 2: Attach a copy of the policy definitions for the insured’s reference. ................
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