Common Contracts
1 similar null 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...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
