HIPAA COMPLIANCE-DATA SECURITY LIABILITY APPLICATION
Section 1: Company & Contact Information
Company Name:
Address:
City:
State:
Zip:
Contact Name:
Telephone:
Fax:
E-Mail:
Web Site:
Year Company Established:
Section 2: Rating Information
Estimated Gross Revenue This Year:
Gross Revenue Last Year:
Please Describe Your Business:
Do you provide data processing, data storage or data hosting services to third parties?
Do you sell products on a wholesale basis?
Do you anticipate significant changes in the size or nature of your business over the next 12 months? If so, please describe:
Section 3: Information Security & Privacy Controls
Do you have, and require employees to follow, written computer and information systems policies and procedures?
Do you use the following controls?
If not, please describe alternate controls in place to prevent unauthorized access to computer systems:
Commercially available firewall protection
Commercially available anti-virus protection?
Do you terminate all computer access and user accounts as part of the regular exit process when an employee leaves the company or when a third party contractor no longer provides the contracted service?
Do you take credit cards?
If Yes, what is the approximate percentage of revenue received by credit card payment?
If Yes, are you compliant with applicable data security standards issued by financial institutions with which you transact business (e.g. PCI standards)?
%
Do you have, and enforce, policies concerning the encryption of internal and external communication?
Are users able to store data to the hard drive of a portable computer or portable media device such as a USB thumb drive?
Please describe any additional controls you have implemented to protect data on portable storage devices:
What format does the applicant use for backing up and storing computer data?
Are tapes or other portable media containing backup material encrypted?
Are tapes or other portable media stored offsite using secured transportation and secured storage facilities?
Submit For Quote
Section 4: Website Controls
Please check all descriptions of website content that you post:
Do you have a procedure for responding to allegations that content displayed, created or published by the applicant is libelous, infringing, or in violation of a 3rd party's privacy rights?
Do you have a process to review all content prior to posting on your web site(s) to avoid the posting of improper or infringing content?
Have you screened all trademarks and service marks used by the applicant for infringement of existing marks prior to first use?
Section 5: Prior Claims and Circumstances
Have you or any other proposed insured, or any director, officer or employee, have knowledge of, or information regarding, any fact, circumstance, situatuion, 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:
During the past 5 years have you:
Received and claims or complaints with respect to privacy, breach of information or network security, unauthorized disclosure of information, or defamation or content infringement?
Been subject to any governmant action, investigation or subpoena regarding any alleged violation of privacy law or regulation?
Notified customers or any other 3rd party of a data breach incident?
Experienced an actual or attempted extortion demand with respect to your computer system?
Type Your Name to Sign Here:
THE OVERSIGNED IS AUTHORIZED BY THE APPLICANT TO SIGN THIS APPLICATION ON THE APPLICANT'S BEHALF AND DECLARES THAT THE STATEMENTS SET FORTH HEREIN AND ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE INSURER IN CONJUNCTION WITH THIS APPLICATION ARE TRUE. 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, ANY SUPPLEMENTAL APPLICATIONS 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.

THIS APPLICATION AND MATERIALS SUBMITTED WITH IT SHAL BE RETAINED ON WILE WITH THE INSURER AND SHALL BE DEEMED ATTACHED TO AND BECOME PART OF THE POLICY IF ISSUED. THE INSURER IS AUTHORIZED TO MAKE ANY INVESTIGATION AND INQUIRY IN CONNECTION WITH THIS APPLICATION AS IT DEEMS NECESSARY.

tHE APPLICANT AGREES THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION 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 INSURER MAY WITHDRAW OR MODIFY ANY OUTSTANDING QUOTATIONS OR AUTHORIZATIONS OR AGREEMENTS TO BIND THE INSURANCE.
Fraud Warning Disclosure
ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT (S)HE IS FACILITATING A FRAUD AGAINST THE INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Tape or Other Media
Online Backup Service
Other:
YesNo
No Website
Information Created In-House
Content Licensed from 3rd Party
Streaming Video or Music Content
Unlicensed 3rd Party Content (e.g. Blog)
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo