FailSafe Enterprise Liability Expense Application - Flight for life insurance colorado

|This application is for a Claims Made Policy. |

|Name of Insurer | | |

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|[pic] Release 4.2 [pic] |

| |Agent Name: | |Agent License Number: | |

|The Basics |

|The words You, Your and Yours in this application means all of the following: the entity indicated in question ( below (the “Applicant”); all subsidiaries in which |

|the Applicant has more than a 50% ownership interest; and all officers, directors, owners, partners and employees of the aforementioned entities. The words We, Us |

|and Our means the Insurer named above. |

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|( |Name of Applicant (use the complete legal entity name as it should appear on the policy) |

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|( |Please list all subsidiaries of the Applicant |

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|( |Applicant’s Address (provide mailing & physical address if they’re not the same) |

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| |List foreign countries You have physical offices in, if any. |

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|( |How many years has the Applicant been in business? _________ |

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|( |List all of Your Websites. Include all URLs registered in Your name. |

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| |If a description of Your products / services is not available on Your website(s), please include additional information (brochure, summary of products / |

| |services, etc.) when You submit the application. You are also welcome to include any other information You think may help Us understand what You do. |

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|( |Desired limit of liability: $250,000 $500,000 $1,000,000 $5,000,000 $ |

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| |Desired Retention: $2,500 $5,000 $10,000 $25,000 $50,000 $100,000 $ |

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|( |If the Applicant currently has Errors & Omissions (E&O) insurance with a Company other than the Hartford, please provide: |

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| |Limit of Liability |$ | | |Expiration Date | |

| |Deductible/SIR |$ | | |Retroactive Date | |

| |First Party Limit(s) |$ | | |First Party Deductible / SIR |$ |

| |Premium |$ | | |Insurance Company | |

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|( |Is this Your first time purchasing this coverage? Yes No |

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|( |Are You purchasing or seeking to purchase E&O insurance to comply with a Contract requirement? Yes No |

| |If Yes, please provide a complete copy of contract, including Statements of Work and annual revenue expectations for such contract. |

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|( |Have You acquired or merged with any companies in the past 3 Years? Yes No |

| |If Yes, please provide the name of each company and the applicable date of acquisition / merger. |

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|Expense and Claims Made Disclosure |

|THIS APPLICATION IS FOR A CLAIMS FIRST MADE POLICY. PLEASE CONTACT YOUR AGENT OR BROKER IF YOU HAVE ANY QUESTIONS. THE POLICY, IF ISSUED, APPLIES ONLY TO CLAIMS |

|WHEN THE WRONGFUL ACT OCCURS ON OR AFTER THE RETROACTIVE DATE AND BEFORE THE END OF THE POLICY PERIOD, AND THE CLAIM IS FIRST MADE AGAINST ANY OF YOU DURING THE |

|POLICY PERIOD. AN EXTENDED REPORTING PERIOD MAY ALSO BE AVAILABLE. |

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|Covered claims expenses and damages within the retention amount must be paid by You and do not reduce Limits of Liability. Covered claim expenses and damages above|

|the retention amount are payable under the policy, and may reduce, and may completely exhaust the limits of liability. We shall not be liable for claims expenses |

|or damages after exhaustion of the applicable Limit of Liability. |

|The Money |

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|( |Please confirm the Applicant’s Fiscal Year End Date: | / / |

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|( |Please provide the revenue and expense information for Your operations as requested below: |

| |Domestic |Foreign |Total |Total |

| |Revenues |Revenues |Revenues |Operating Expenses |

|Actual Prior Year | | | | |

|Projected Current Year | | | | |

|Projected Next Year | | | | |

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|If Your financials are not available on Your Website(s), please include Your Income Statement and Current Balance Sheet for the most recently completed fiscal year|

|and the current Year To Date when You submit this application. |

|What You Do |

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|( |Please provide a detailed description of Your products / services: |

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|( |Please provide the percentage of revenue attributable to the following activities for Your company: |

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|Hardware Products / Services: |

| % |Manufacturing / Design of Hardware Products / Components for Others |

| % |Resale of Hardware Products / Components Manufactured by Others |

| % |Installation / Integration / Maintenance of Hardware Products Manufactured by Others |

|Software Products / Services: |

| % |Prepackaged Software Development and Sales |

| % |Custom Programming & Software Development Services |

| % |Software Installation / Integration / Maintenance Services for Software Products of Others |

| % |Application Service Provider (ASP) Services / Software as a Service (SaaS) |

| % |Website Design Services |

|Communication / Connectivity Services: |

| % |Internet Access / Website & Data Hosting / IT Connectivity Services / Infrastructure as a Service (IaaS) |

| % |Telecommunication Services (wire-line, wireless, VoIP, local/long distance telephone services) |

| % |Internet Search Engine, Website Portal, or Social Networking Services |

|Other Information Technology Services: |

| % |IT Networking, Systems Management, & Systems Outsourcing Services |

| % |Information Security Services (network vulnerability & penetration testing; intrusion detection services, etc) |

| % |IT Consulting Services (strictly providing advice and direction on information technology) |

| % |IT Staffing Services (Please indicate % of: Time & Materials Work % Project/Deliverables/Turnkey Work %) |

| % |Other IT Services (Please describe): |

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|Non-Technology Products / Services: (accounting, architectural, engineering, legal, medical, insurance, etc.) |

| % |(Please describe): |

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|Who You Do It For |

|( |Please provide the percentage of Your revenue attributable to the following industries: |

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| % |Federal Government (Prime Contractor and/or Subcontractor) | % |Aerospace / Aircraft / Aviation |

| % |Local / State Government (Prime Contractor and/or Subcontractor) | % |Banking / Investment / Financial Services |

| % |Biotechnology / Life Science / Pharmaceutical / Renewable Energy | % |Insurance |

| % |Medical / Healthcare | % |Manufacturing / Industrial |

| % |Entertainment / Broadcasting / Gaming | % |Law Firms / Accounting Firms |

| % |Information Technology / Telecommunications | | |

| % |Other (Please describe): |

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|What It Does |

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|( |Please provide a detailed description of the applicable end use(s) of Your products / services for Your customers: |

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|( |Please provide the percentage of revenue attributable to the following end use(s) of Your products / services: |

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| % |Medical Purposes (diagnostics, patient care / treatment, non-administrative medical applications, etc.) |

| % |Aerospace Applications (flight control, guidance systems, aircraft tracking and warning systems, etc.) |

| % |Defense / Military Applications (warfare, weapon & targeting systems; non-administrative military applications, etc.) |

| % |Training & Education Purposes (products / services used to train/educate others on information technology products) |

| % |Fire / Physical Security / Emergency Applications |

| % |Information and Computer Systems Security Advice / Products |

| % |Network / Systems Administration |

| % |Business Intelligence / Data Management |

| % |Communication Applications (voice / data / internet connectivity technologies) |

| % |Financial Transaction Applications (funds transfer, trading, financial modeling, credit card transactions, etc.) |

| % |Accounting / Financial Applications (excluding those indicated as Financial Transactions above) |

| % |Administrative Applications (sales, marketing, billing, human resources, etc.) |

| % |Physical Process / Manufacturing Process Controls (robotics, automation, PLC, CAM, CAE, etc.) |

| % |Multi-media / Gaming Applications |

| % |Social Media / Social Networking |

| % |Other (Please describe): |

|Your Team |

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|( |Composition of Your work force: | | |

| | |# of principals, partners, directors and officers | |# of clerical / support personnel |

| | |# of technical personnel | |# of sales and marketing personnel |

| | |# of independent contractors performing services on Your behalf | |# of Other |

| | | |Total # for all categories listed above | |

| | | |% of personnel that work in remote locations Please describe: | |

| | |Average years of experience for technical staff and subcontractors |

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|( |Do You subcontract any activity involved in the research, development, distribution and sale of Your products/services? |

| |Yes No If Yes, please answer a. & b. below |

| |a. |Do You require subcontractors to maintain Errors or Omissions Coverage? Yes No |

| |b. |Identify services You subcontract & how You ensure the quality of these services. |

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|What Could Go Wrong? |

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|( |Please describe the most likely scenario if Your product / service failed: |

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|( |How many users would be affected if Your product / service failed? 1-10 10-100 Over 100 |

| |What is the acceptable downtime for Your product / service according to Your average customer’s needs? |

| |None Less than 1 day Less than 2 days More than 2 days |

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|( |Do You warrant or guarantee any standards of performance for Your products/services? (i.e. no service interruptions, delivery / completion time frames, |

| |volume of transactions, etc.) Yes No If Yes, please describe: |

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|( |Do You ever warrant or guarantee that Your product / service has no security vulnerabilities or that Your service will prevent security breaches, the |

| |introduction/transfer of malicious code, etc.? Yes No If Yes, please describe: |

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|Contractual Risk Management & Customer Support |

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|( |Please indicate the estimated percentage of time You utilize the following in Your engagements with customers: |

| % |Your Standard Customer Contract with no Modifications (please provide copy with application) |

| % |Your Standard Customer Contract with Modifications (not including pricing modification) |

| % |Customer Provided Contract with no Modifications |

| % |Customer Provided Contract with Modifications |

| % |No contractual agreement with Your customer |

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|( |The following provisions, when negotiated in Your favor, can offer clarity & insulation in the event of a dispute. Which of the following provisions do You |

| |include, in Your favor, in Your standard contracts / agreements with customers? (check all that apply) |

| Liability Disclaimer of Consequential Damages |

|Disclaimer of Warranty - General |

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|Limitation of Liability – Damages Cap |

|Disclaimer of Warranty for Security of Clients’ Systems |

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|( |Do You ever negotiate contracts with a customer where You are liable for consequential, liquidated, multiplied, or punitive damages? Yes No If Yes, |

| |please indicate how often and under what circumstances. |

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|( |Do You ever negotiate contracts with a customer where Your liability is not explicitly limited within the agreement? |

| |Yes No If Yes, please indicate how often and describe these situations. |

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|( |How many customers do You currently have? What is Your customer growth rate? % |

| |What is the size & length of Your average customer contract? |$ | Months | Years |

| |What is the size & length of Your largest customer contract? |$ | Months | Years |

| |Name of largest customer & detailed description of work performed. Please provide copy of contract |

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|( |Check (() all items that are elements of Your quality control & customer support programs, if applicable. Check all that apply. |

| |Written & formalized quality control program |

| |Customer signature on each phase of project and change-order |

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| |Recall Plan |

| |Formal customer acceptance procedures |

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| |Formal Customer Notification / Escalation Procedures |

| |Dedicated Customer Service Support M-F 24/7 |

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|IT Operations, Privacy & Security |

|( |Do You or a 3rd Party on Your behalf: collect, control, or store sensitive information of others? Yes No |

| |If yes, please check all that apply and provide approximate number of records. |

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| Social Security Numbers: |

|________ |

|Healthcare Records: |

|________ |

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|Payment Card Information: |

|________ |

|Medical Identification Information: |

|________ |

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|Drivers’ License Numbers: |

|________ |

|Credit Rating Information: |

|________ |

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|Financial Account Numbers: |

|________ |

|User Names and Passwords: |

|________ |

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|Biometric Data: |

|________ |

|Other Government ID Numbers: |

|________ |

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|Other: ____________________ |

|________ |

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| |What % of the above are records within Your care, custody & control? % With a 3rd Party on Your behalf? % |

| |What % of the above are records of employees and / or individual independent contractors? % |

| |What are Your purging timelines and procedures (for records no longer in use)? Please confirm whether Your procedures include permanently erasing or |

| |destroying the data using a technique that leaves no residual data. |

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|( |Privacy Policies / Procedures / Controls: |

| |a. |Do You have a corporate privacy policy for handling confidential / sensitive information? Yes No |

| |b. |Do You train employees on handling of sensitive information? Yes No How often? |

| |c. |For sensitive information indicated above, is information collected with authorization of those whose information is being collected (e.g. in the form |

| | |of an opt-in agreement)? Yes No If Yes, on what basis? Opt-in Opt-out |

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|( |Please indicate the operation(s) outsourced and the name of the third party vendor(s)? |

| |Outsourced Service |

| |Vendor |

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| |Outsourced Service |

| |Vendor |

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| |Network Operations/Data Center |

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| |Data Storage/Back-up/Recovery |

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| |Hosting: Corporate Applications |

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| |Network Security Services |

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| |Hosting: Customer Applications |

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| |Other |

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| |Do Your contracts with these third parties specify privacy and security requirements and responsibilities? Yes No |

| |Do these third parties indemnify You for damages & losses, including notification costs, arising from data breach? Yes No |

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|( |Please check (() all IT Risk Management elements implemented by You or 3rd Party holding sensitive information on Your behalf: |

| |Data Protection |

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| | Inventory of Authorized / Unauthorized Devices & Software |

| |You 3rd Party |

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| | Encryption of Data at rest & in motion on desktops, laptops, mobile equipment & servers |

| |You 3rd Party |

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| | Continuous Vulnerability Assessment / Remediation, Patch Management & Intrusion Detection |

| |You 3rd Party |

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| | Maintenance, Monitoring & Analysis of Audit Logs |

| |You 3rd Party |

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| | Email & Web Protections (e.g. Monitoring Data Outflows / Incoming Attachments / URL Filters) |

| |You 3rd Party |

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| | Multi-Factor Authentication |

| |You 3rd Party |

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| | Database and Network Segmentation |

| |You 3rd Party |

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| | Active Management of Security Configurations for Firewalls, Routers, Switches & Devices |

| |You 3rd Party |

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| | Anti-malware Software Automation |

| |You 3rd Party |

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| | Practiced Security Breach Response Plan |

| |You 3rd Party |

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| | Periodic Security Audits including Penetration Testing by 3rd Parties |

| |You 3rd Party |

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| |Employee Access Management |

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| | Employee Security Skills, Awareness, & Assessment / Training |

| |You 3rd Party |

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| | Secure Remote Access Capabilities ( e.g. VPN) |

| |You 3rd Party |

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| | Controlled Use of Administrative Privileges & Access to Sensitive Data |

| |You 3rd Party |

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| | Procedure for Departed Employees / 3rd Parties (e.g. immediate termination of accounts & access) |

| |You 3rd Party |

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|( |Business Income Loss & Data Restoration |

| |Do You have an alternative processing site to maintain uptime & business function? Yes No |

| |Do You have an alternative storage site that maintains duplicate copies of operating systems, app software, and data? Yes No |

| |Please indicate the type and frequency of backup procedures You have in place: |

| |Type of Backup (check all that apply) |

| |Frequency of Backup |

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| |Full Backup |

| | Daily Weekly Monthly Never |

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| |Incremental Backup |

| | Daily Weekly Monthly Never |

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| |Differential Backup |

| | Daily Weekly Monthly Never |

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|( |What percentage of Your annual revenue is derived from e-Commerce / internet sales? % |

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|( |Are You a Business Associate under HIPAA? Yes No |

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|( |Are You compliant with Payment Card Industry Data Security Standards? Yes No (Please provide copy of compliance report) |

| |What is Your Visa Merchant Level? 1 (6M+ transactions) 2 (1M to 6M transactions) 3 (20k to 1M transactions) 4 ( ................
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