PRIOR CLAIMS AND CIRCUMSTANCES. 1. Does the Applicant or other proposed insured, or any director, officer or employee of the Applicant or other proposed insured have knowledge of or information regarding any fact, circumstance, situation, event or transaction which may give rise to a claim or loss or obligation to provide breach notification under the proposed insurance? If yes, please provide details: Yes No
2. During the past 5 years has the Applicant: A. received any claims or complaints with respect to privacy, breach of information or network security, unauthorized disclosure of information, or defamation or content infringement? B. been subject to any government action, investigation or subpoena regarding any alleged violation of a privacy law or regulation? C. notified consumers or any other third party of a data breach incident involving the Applicant? D. Experienced an actual or attempted extortion demand with respect to its computer systems? Yes No Yes No Yes No Yes No THE UNDERSIGNED AUTHORIZED EMPLOYEE OF THE APPLICANT DECLARES THAT THE STATEMENTS SET FORTH HEREIN ARE TRUE. THE UNDERSIGNED AUTHORIZED EMPLOYEE AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE EFFECTIVE DATE OF THE INSURANCE, HE/SHE WILL, IN ORDER FOR THE INFORMATION TO BE ACCURATE ON THE EFFECTIVE DATE OF THE INSURANCE, IMMEDIATELY NOTIFY THE UNDERWRITER OF SUCH CHANGES, AND THE UNDERWRITER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. FOR NEW HAMPSHIRE APPLICANTS, THE FOREGOING STATEMENT IS LIMITED TO THE BEST OF THE UNDERSIGNED’S KNOWLEDGE, AFTER REASONABLE INQUIRY. IN MAINE, THE UNDERWRITERS MAY MODIFY BUT MAY NOT WITHDRAW ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE. NOTHING CONTAINED HEREIN OR INCORPORATED HEREIN BY REFERENCE SHALL CONSTITUTE NOTICE OF A CLAIM OR POTENTIAL CLAIM SO AS TO TRIGGER COVERAGE UNDER ANY CONTRACT OF INSURANCE. NO COVERAGE SHALL BE AFFORDED FOR ANY CLAIMS ARISING OUT OF A CIRCUMSTANCE NOT DISCLOSED IN THIS APPLICATION. SIGNING OF THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE UNDERWRITER TO COMPLETE THE INSURANCE, BUT IT IS AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED, AND IT WILL BECOME PART OF THE POLICY. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PA...
PRIOR CLAIMS AND CIRCUMSTANCES. Does the Applicant or any other proposed insured (including any director, officer or employee) have knowledge of or any information regarding any fact, circumstance, situation, event or transaction which may give rise to a claim, loss or obligation to provide breach notification under the proposed insurance? If yes, please provide details: ☐ Yes ☐ No During the past five years has the company: ☐ Please check if the Applicant does not have any claims or circumstances to report within the past five years (If checked, please skip questions A- D).
PRIOR CLAIMS AND CIRCUMSTANCES. 1. Has the Applicant ever received any claims or complaints with respect to allegations of invasion of or injury to privacy, identity theft, theft of information, breach of information security, software copyright infringement or content infringement or been required to provide notification to individuals due to an actual or suspected disclosure of personal information? Yes No If yes, Provide details of each such claim, allegation or incident, including costs, losses or damages incurred or paid, and any amounts paid as a loss under any insurance policy:
2. Has the Applicant been subject to any government action, investigation or subpoena regarding any alleged violation of any law or regulation? Yes No If yes, please provide details of any such action, investigation or subpoena:
3. Has the Applicant ever experienced an extortion attempt or demand with respect to its computer systems? Yes No If yes, please provide details:
4. Has the Applicant notified consumers of a data breach incident in accordance with a data breach notification law in the past three (3) years? Yes No If yes, please provide details:
5. Does the Applicant, or any director, officer, employee or other proposed insured have knowledge or information of any fact, circumstance, situation, event or transaction which may give rise to a claim or privacy breach notification under the proposed insurance? Yes No
PRIOR CLAIMS AND CIRCUMSTANCES arising out of, based upon or attributable to:
(i) any facts alleged or the same or related Wrongful Acts or the same or related Corporate Wrongful Acts alleged or contained in any circumstance or Insured Event of which notice has been given under any policy of which this Policy is a renewal or replacement or which it may succeed in time;
(ii) any pending or prior civil, criminal, administrative or regulatory proceeding, investigation, arbitration, mediation, other dispute resolution or adjudication as of the Continuity Date, or alleging or deriving from the same or essentially the same facts alleged in such actions; or
(iii) any Insured Event that would otherwise constitute a Single Claim with any claim or other matter reported under any policy of which this Policy is a renewal or replacement or which it may succeed in time. Exclusion 5.2 (i)(Conduct) shall not apply to any circumstances which have been notified to the Insurer under any earlier policy, but were not accepted by the Insurer as a valid notification, and where cover has been maintained continuously with the Insurer from the inception date of such earlier policy until the expiry date of this Policy.
PRIOR CLAIMS AND CIRCUMSTANCES. 1. Does the Applicant or other proposed insured, or any director, officer or employee of the Applicant or other proposed insured have knowledge of or information regarding any fact, circumstance, situation, event or transaction which may give rise to a claim or loss or obligation to provide breach notification under the proposed insurance? If yes, please provide details: Yes No
2. During the past 5 years has the Applicant: A. received any claims or complaints with respect to privacy, breach of information or network security, unauthorized disclosure of information, or defamation or content infringement? Yes No
B. been subject to any government action, investigation or subpoena regarding any alleged violation of a privacy law or regulation? Yes No C. notified consumers or any other third party of a data breach incident involving the Applicant? Yes No D. Experienced an actual or attempted extortion demand with respect to its computer systems? Yes No If yes, please provide details of any such action, notification, investigation or subpoena:
PRIOR CLAIMS AND CIRCUMSTANCES arising out of, based upon or attributable to:
(i) any incident or circumstance known to the insured prior to the retroactive date of this policy, which may give rise to a Claim under this policy.
(ii) any Claim which has been reported or any incident or circumstance for which notice has been given under any other policy of which this policy is a renewal or replacement or which it may succeed in time; or
(iii) any litigation or pending litigation instituted prior to the inception of this policy or any allegation arising or emanating from the same or essentially the same facts as alleged in such litigation. For the purposes of this exclusion, the term litigation shall include, but not be limited to, any civil, administrative or regulatory proceeding or official Investigation, arbitration, mediation or adjudication.
PRIOR CLAIMS AND CIRCUMSTANCES. 1. Has the Applicant ever been received complaints or been investigated in respect of the safeguards for personally identifiable information? If yes, please explain If Yes, provide details of such claim, allegation or incident, including costs, losses or damages incurred or paid, and any amounts paid as a loss under any insurance policy. Yes No
2. Is any Applicant, director, officer or other proposed Insured have knowledge or information of any fact, circumstance, situation, event or transaction which may give rise to a Claim under the proposed insurance? If Yes, provide details on a separate sheet. Yes No
PRIOR CLAIMS AND CIRCUMSTANCES. 1. Has the applicant ever received complaints or been investigated regarding safeguards for personally identifiable information? If yes, provide details of such claim, allegation or incident, including costs, losses or damages incurred or paid, and any amounts paid as a loss under any insurance policy. Yes No
2. Does any applicant, director, officer or other proposed Insured have knowledge or information of any fact, circumstance, situation, event or transaction which may give rise to a claim under the proposed insurance? If yes, provide details on a separate sheet. Yes No The undersigned declares that the statements set forth herein are true. The signing of this application does not bind the undersigned or the Insurer to complete the insurance. It is represented that the statements contained in this application 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. The Insurer is authorized to make any investigation and inquiry in connection with this Application as it deems necessary. Nothing contained herein or incorporated herein by reference shall constitute notice of a claim or potential claim so as to trigger coverage under any contract of insurance. It is agreed in the event there is any material change in the answers to the questions contained in this application prior to the effective date of the policy, the applicant will immediately notify the Insurer in writing and any outstanding quotations may be modified or withdrawn at the Insurer’s discretion. FRAUD WARNINGS Signed: Must be signed by corporate officer with authority to sign on the applicant’s behalf Printed Name: _________________________________________________ Title: _________________________________________________________ Date: ________________________________________________________ 1 The officer of the applicant that is designated to receive any and all notices from the Insurer or its authorized representative(s) concerning this insurance.
