City State Zip CodeInsurance Application • July 17th, 2001 • Provident Mutual Variable Annuity Separate Account
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 13th, 2008
GENERAL INFORMATION: Full Name: Mailing Address: State of Inc: City: State & Zip: Date Est: Website URL’s: Breach Response Contact: Email: Telephone: Please describe in detail the nature and types of professional and/or technology services the Applicant is engaged in and the types of Technology Products developed, manufactured, licensed or sold: REVENUE INFORMATION: *For all other Applicants, please provide Gross Revenue information Past Twelve Months: Previous Year Next Year (Estimate) US Revenue: USD USD USD Non-US Revenue: USD USD USD Total: USD USD USD
ApplicaitonInsurance Application • September 28th, 2018
IMPORTANT NOTICE: INSURING AGREEMENTS B AND C OF THE INSURANCE POLICY FOR WHICH THIS APPLICATION IS MADE (HEREINAFTER REFERRED TO AS THE “POLICY”) ARE WRITTEN ON A CLAIMS MADE AND REPORTED BASIS AND ONLY COVER CLAIMS FIRST MADE AGAINST THE INSURED...Insurance Application • September 21st, 2023
THE HARTFORD CRIMESHIELDSM ADVANCED POLICY APPLICATION FOR CHURCHES, MOSQUES, SYNAGOGUES & OTHER HOUSES OF WORSHIPInsurance Application • November 25th, 2013
Application for Insurance No. ___________Insurance Application • April 8th, 2019
Is the buyer part of a Group (a Group is comprised of a parent company and all subsidiary companies)? ☐ No ☐ Yes (state general data on the Group):
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
