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
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:
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). A. Received any claims or complaints with respect to privacy, breach of information or network security, or unauthorized disclosure of information? B. Been subject to any government action, investigation or subpoena regarding any alleged violation of a privacy law or regulation? C. Notified customers or any other third party of a data breach incident involving the Applicant? D. Experienced an actual of attempted extortion demand with respect to its computer systems? ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☐ No SIGNATURE SECTION THE UNDERSIGNED IS AUTHORIZED BY THE APPLICANT TO SIGN THIS APPLICATION ON THE APPLICANT’S BEHALF AND DECLARES THAT THE STATEMENTS CONTAINED IN THE INFORMATION AND MATERIALS PROVIDED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION AND THE UNDEWRITING OF THIS INSURANCE ARE TRUE, ACCURATE AND NOT MISLEADING. 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 AND ANY OTHER INFORMATION AND MATERIALS SUBMITTED TO THE INSURER IN CONNECTION WITH THE UNDERWRITING OF THIS INSURANCE 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 ALL INFORMATION AND MATERIALS SUBMITTED WITH IT SHALL BE RETAINED ON FILE WITH THE INSURER. THE INSURER IS AUTHORIZED TO MAKE ANY INVESTIGATION AND INQUIRY AS IT DEEMS NECESSARY REGARDING THE INFORMATION AND MATERIALS PROVIDED TO THE INSURER IN CONNECTION WITH THE UNDERWRITING AND ISSUANCE OF THE POLICY. THE APPLICANT AGREES THAT IF THE INFORMATION PROVIDED IN THIS APPLICATION OR IN CONNECTION WITH THE UNDERWRITING OF THE POLICY 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 I...
PRIOR CLAIMS AND CIRCUMSTANCES arising out of, based upon or attributable to:
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 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
