Common Contracts
1 similar Insurance Application contracts
NOTICE: THIS POLICY’S LIABILITY INSURING AGREEMENTS PROVIDE COVERAGE ON A CLAIMS MADE AND REPORTED BASIS AND APPLY ONLY TO CLAIMS FIRST MADE AGAINST THE INSURED DURING THE POLICY PERIOD OR THE OPTIONAL EXTENSION PERIOD (IF APPLICABLE) AND REPORTED TO...Insurance Application • February 2nd, 2018
Full Name: Mailing Address: State of Incorporation: City: State & Zip: # of Employees: Date Established: Website URL’s: Authorized Officer 1: Telephone: E-mail: Breach Response Contact 2: Telephone: E-mail: Business Description: Does the Applicant provide data processing, storage or hosting services to third parties? Yes No REVENUE INFORMATION *For Applicants in Healthcare: Net Patient Services Revenue plus Other Operating Revenue*For all other Applicants, please provide Gross Revenue information Most Recent Twelve (12) months: (ending: / ) Previous Year Next Year (estimate) US Revenue: USD USD USD Non-US Revenue: USD USD USD Total: USD USD USD
