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DATASURE FIRST-PARTY COVERAGE

NETWORK SECURITY QUESTIONNAIRE


1. Applicant Name:
2. Please indicate what types of electronic data records of employees and/or customers the Applicant stores on its
computer system? (Please check all that apply.)
onetary transactions
!ecurities
edical data
"ustomer information
"redit card information
#rade secrets
$mployee information
%ntellectual property assets
&. %n the past fi'e years has the Applicant e(perienced a security )reach to its computer systems? *es No
%f yes+ please e(plain and identify the steps taken to pre'ent future security )reaches to the Applicant,s computer
systems.
-. .as the Applicant e'er had to notify a customer/client of a )reach in network security that may ha'e affected their
information? *es No
%f yes+ please pro'ide written details.
/. 0oes the Applicant transmit credit card+ customer+ employee+ medical+ monetary or financial information throu1h
wireless routers to )anks for appro'al or to the Applicant,s central computer systems? *es No
%f yes+ does the Applicant utili2e 3ired $4ui'alent Pri'acy (3$P) security protocol? *es No
Please e(plain and identify any steps taken to up1rade the Applicant,s 3ired $4ui'alent Pri'acy (3$P) security
protocol.
%f the Applicant does not utili2e 3$P security protocol+ does the Applicant utili2e 3i56i Protected Access (3PA) or 3i5
6i Protected Access 2 (3PA2) security protocol? *es No
Please e(plain and identify any steps taken to up1rade the Applicant,s 3i56i Protected Access (3PA) or 3i56i
Protected Access 2 (3PA2) security protocol.
7. 0oes the Applicant transact )usiness utili2in1 de)it+ credit+ pre5paid+ e5purse+ A# and/or P8! cards? *es No
%f yes+ is the Applicant compliant with the Payment "ard %ndustry !ecurity !tandards and the 6air and Accurate "redit
#ransactions Act (6A"#A)? *es No
%f no+ what steps has the Applicant taken+ or is undertakin1 to )ecome compliant with the Payment "ard %ndustry
!ecurity !tandards and the 6air and Accurate "redit #ransactions Act (6A"#A)?
9. 0oes the Applicant ha'e a person+ 1roup or outside information security firm responsi)le for its information security?
*es No
%f yes+ please pro'ide written details concernin1 the person,s+ 1roup,s or outside firm,s e(perience le'el and
responsi)ilities.
:. 0oes the Applicant or the Applicant,s outside information security firm ha'e procedures in place for notifyin1
customers/clients of a )reach in network security that may ha'e affected their information? *es No
%f yes+ please pro'ide written details.
;. 0oes the Applicant or the Applicant,s outside information security firm monitor the Applicant,s network in real time to
detect possi)le intrusions or a)normalities in the performance of the Applicant,s system? *es No
%f yes+ please pro'ide written details re1ardin1 who is notified and how lon1 it would take for correcti'e action to )e
taken once a security )reach is detected.
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1<. 0escri)e the security measures used to pre'ent unauthori2ed access to:
A. the Applicant,s premises and facilities:
A. the Applicant,s computer systems/ser'ers entrusted to others:
". the Applicant,s computer systems/ser'ers entrusted to employees:
0. the Applicant,s computer systems/ser'ers located on the Applicant,s premises:
$. computer systems/ser'ices of others in the Applicant,s care+ custody and/or control:
11. 0escri)e the security measures used )y the Applicant to protect confidentiality and inte1rity of data.
12. Ad'ise technolo1y the Applicant uses for:
A. $ncryption:
A. Authentication:
". Anti5'irus:
1&. 0oes the Applicant perform security audits? *es No
%f yes+ please ad'ise the followin1:
A. who performs the audit?
A. how fre4uently are the audits performed?
". what actions ha'e )een taken to correct any unfa'ora)le results?
1-. A. 0oes the Applicant ha'e a formal+ documented security policy? *es No
A. 0oes the Applicant document that all employees ha'e read and understand the Applicant,s security policy?
*es No
1/. Aackup of the Applicant,s computer systems and data:
A. how often are )ackups performed?
A. are )ackups stored off site? *es No
Answer Questions 1!-1"! on#$ i% &usiness Interru'tion or D(t( Restor(tion )o*er(+e is re,ueste-!
17. 3hat is the Applicant,s total annual net income+ 1ross receipts+ donations or 1rants 1enerated from or dependent
upon the Applicant,s computer system?
Net %ncome
Bross @eceipts
0onations
Brants
19. 3hat is the Applicant,s a'era1e -(i#$ net income+ 1ross receipts+ donations or 1rants 1enerated from or dependent
upon the Applicant,s computer system?
Net %ncome
Bross @eceipts
0onations
Brants
1:. 3hat are the Applicant,s estimated e(tra e(penses and ordinary payroll+ which the Applicant anticipates keepin1
employed+ if operations are shut down for an e(tended period of time as a result of a computer attack?
1;. %n the last / years has the Applicant had any losses in'ol'in1 )usiness interruption+ )usiness restoration e(penses+
data restoration e(penses+ or crisis mana1ement e(penses due to a computer attack or system failure? *es No
%f yes+ please pro'ide details of each incident.
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REPRESENTATIONS .
By signing this application, the applicant agrees that:
1. #he statements and answers furnished to the "ompany in this application and any attachments to it are accurate and completeC
2. #he statements and answers furnished to the "ompany are representations the applicant makes to the "ompany on )ehalf of all
persons and entities proposed for co'era1eC
&. #hose representations are a material inducement to the "ompany to pro'ide a proposal for insuranceC
-. Any policy the "ompany issues will )e issued in reliance upon those representationsC
/. #his 4uestionnaire+ includin1 any attachments+ and all other information and materials su)mitted )y or on )ehalf of the Applicant to
the "ompany in connection with the "ompany underwritin1 any policy+ will )e kept on file )y the "ompany+ deemed attached to the
policy as if physically attached to it and shall )ecome incorporated in and constitute a part of the policyC
7. #he applicant will report to the "ompany immediately+ in writin1+ any material chan1e to the applicant,s operations+
conditions or answers pro'ided in this application that occur or are disco'ered )etween the date of this application and the
effecti'e date of any policy+ if issuedC and
9. #he "ompany reser'es the ri1ht+ upon receipt of any such notice+ to modify or withdraw any proposal for insurance the "ompany
has offered.
WARNING
ANY PERSON W/O0 WIT/ INTENT TO DEFRAUD OR KNOWING T/AT S1/E2 IS FACI3ITATING A FRAUD AGAINST
T/E INSURER0 SU&4ITS AN APP3ICATION OR FI3ES A C3AI4 CONTAINING A FA3SE OR DECEPTIVE
STATE4ENT 4AY &E GUI3TY OF INSURANCE FRAUD!

NA4E 1P3EASE TYPE OR PRINT2 NA4E 1SIGNATURE OF AUT/ORI5ED REPRESENTATIVE2

TIT3E DATE
TO &E CO4P3ETED &Y PRODUCER1S2 ON3Y6
RETAI3 PRODUCER6
Pro-u)er N(7e6
Cit$0 St(te6
Te#e'8one No!6



W/O3ESA3E PRODUCER6
Pro-u)er N(7e6
Cit$0 St(te6
Te#e'8one No!6



NEW /A4PS/IRE SURP3US 3INES AGENT IDENTIFICATION NU4&ER6
NOTE6 AGENT9&ROKER IS RESPONSI&3E FOR CO33ECTION AND FI3ING OF ANY SURP3US 3INES TA:ES AND FEES T/AT 4AY APP3Y!
NOTICE TO ARKANSAS APPLICANTS:
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A "@%$ AN0 A* A$ !?AF$"# #8 6%N$! AN0 "8N6%N$$N# %N P@%!8N.
NOTICE TO COLORADO APPLICANTS:
%# %! ?NEA36?E #8 DN83%NBE* P@8G%0$ 6AE!$+ %N"8PE$#$+ 8@ %!E$A0%NB 6A"#! 8@ %N68@A#%8N #8
AN %N!?@AN"$ "8PAN* 68@ #.$ P?@P8!$ 86 0$6@A?0%NB 8@ A##$P#%NB #8 0$6@A?0 #.$ "8PAN*.
P$NAE#%$! A* %N"E?0$ %P@%!8N$N#+ 6%N$!+ 0$N%AE 86 %N!?@AN"$ AN0 "%G%E 0AAB$!. AN*
%N!?@AN"$ "8PAN* 8@ AB$N# 86 AN %N!?@AN"$ "8PAN* 3.8 DN83%NBE* P@8G%0$! 6AE!$+
%N"8PE$#$+ 8@ %!E$A0%NB 6A"#! 8@ %N68@A#%8N #8 A P8E%"*.8E0$@ 8@ "EA%AN# 68@ #.$
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"8E8@A08 0%G%!%8N 86 %N!?@AN"$ 3%#.%N #.$ 0$PA@#$N# 86 @$B?EA#8@* AB$N"%$!.
NOTICE TO DISTRICT O COL!"BIA APPLICANTS:
3A@N%NB: %# %! A "@%$ #8 P@8G%0$ 6AE!$ 8@ %!E$A0%NB %N68@A#%8N #8 AN %N!?@$@ 68@ #.$
P?@P8!$ 86 0$6@A?0%NB #.$ %N!?@$@ 8@ AN* 8#.$@ P$@!8N. P$NAE#%$! %N"E?0$ %P@%!8N$N#
AN0/8@ 6%N$!. %N A00%#%8N+ AN %N!?@$@ A* 0$N* %N!?@AN"$ A$N$6%#! %6 6AE!$ %N68@A#%8N
A#$@%AEE* @$EA#$0 #8 A "EA% 3A! P@8G%0$0 A* #.$ APPE%"AN#.
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NOTICE TO LORIDA APPLICANTS:
AN* P$@!8N 3.8 DN83%NBE* AN0 3%#. %N#$N# #8 %NF?@$+ 0$6@A?0+ 8@ 0$"$%G$ AN* %N!?@$@ 6%E$! A
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%N68@A#%8N %! B?%E#* 86 A 6$E8N* 86 #.$ #.%@0 0$B@$$.
NOTICE TO KENT!CK# APPLICANTS:
AN* P$@!8N 3.8 DN83%NBE* AN0 3%#. %N#$N# #8 0$6@A?0 AN* %N!?@AN"$ "8PAN* 8@ 8#.$@
P$@!8N 6%E$! AN APPE%"A#%8N 68@ %N!?@AN"$ "8N#A%N%NB AN* A#$@%AEE* 6AE!$ %N68@A#%8N 8@
"8N"$AE!+ 68@ #.$ P?@P8!$ 86 %!E$A0%NB+ %N68@A#%8N "8N"$@N%NB AN* 6A"# A#$@%AE #.$@$#8
"8%#! A 6@A?0?E$N# %N!?@AN"$ A"#+ 3.%". %! A "@%$.
NOTICE TO LO!ISIANA APPLICANTS:
AN* P$@!8N 3.8 DN83%NBE* P@$!$N#! A 6AE!$ 8@ 6@A?0?E$N# "EA% 68@ PA*$N# 86 A E8!! 8@
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A "@%$ AN0 A* A$ !?AF$"# #8 6%N$! AN0 "8N6%N$$N# %N P@%!8N.
NOTICE TO "AINE APPLICANTS:
%# %! A "@%$ #8 DN83%NBE* P@8G%0$ 6AE!$+ %N"8PE$#$ 8@ %!E$A0%NB %N68@A#%8N #8 AN
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%P@%!8N$N#+ 6%N$! 8@ A 0$N%AE 86 %N!?@AN"$ A$N$6%#!.
NOTICE TO "AR#LAND APPLICANTS:
AN* P$@!8N 3.8 DN83%NBE* AN0 3%EE6?EE* P@$!$N#! A 6AE!$ 8@ 6@A?0?E$N# "EA% 68@ PA*$N#
86 A E8!! 8@ A$N$6%# 8@ 3.8 DN83%NBE* AN0 3%EE6?EE* P@$!$N#! 6AE!$ %N68@A#%8N %N AN
APPE%"A#%8N 68@ %N!?@AN"$ %! B?%E#* 86 A "@%$ AN0 A* A$ !?AF$"# #8 6%N$! AN0 "8N6%N$$N# %N
P@%!8N.
NOTICE TO NE$ %ERSE# APPLICANTS:
AN* P$@!8N 3.8 %N"E?0$! AN* 6AE!$ 8@ %!E$A0%NB %N68@A#%8N 8N AN APPE%"A#%8N 68@ AN
%N!?@AN"$ P8E%"* %! !?AF$"# #8 "@%%NAE AN0 "%G%E P$NAE#%$!.
NOTICE TO NE$ "E&ICO APPLICANTS:
AN* P$@!8N 3.8 DN83%NBE* P@$!$N#! A 6AE!$ 8@ 6@A?0?E$N# "EA% 68@ PA*$N# 86 A E8!! 8@
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A "@%$ AN0 A* A$ !?AF$"# #8 "%G%E 6%N$! AN0 "@%%NAE P$NAE#%$!.
NOTICE TO NE$ #ORK APPLICANTS:
AN* P$@!8N 3.8 DN83%NBE* AN0 3%#. %N#$N# #8 0$6@A?0 AN* %N!?@AN"$ "8PAN* 8@ 8#.$@
P$@!8N 6%E$! AN APPE%"A#%8N 68@ %N!?@AN"$ 8@ !#A#$$N# 86 "EA% "8N#A%N%NB AN* A#$@%AEE*
6AE!$ %N68@A#%8N+ 8@ "8N"$AE! 68@ #.$ P?@P8!$ 86 %!E$A0%NB+ %N68@A#%8N "8N"$@N%NB AN*
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"EA% 68@ $A". !?". G%8EA#%8N.
NOTICE TO O'IO APPLICANTS:
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B?%E#* 86 %N!?@AN"$ 6@A?0.
NOTICE TO OKLA'O"A APPLICANTS:
3A@N%NB: AN* P$@!8N 3.8 DN83%NBE*+ AN0 3%#. %N#$N# #8 %NF?@$+ 0$6@A?0 8@ 0$"$%G$ AN*
%N!?@$@+ AD$! AN* "EA% 68@ #.$ P@8"$$0! 86 AN %N!?@AN"$ P8E%"* "8N#A%N%NB AN* 6AE!$+
%N"8PE$#$ 8@ %!E$A0%NB %N68@A#%8N %! B?%E#* 86 A 6$E8N*.
NOTICE TO PENNS#L(ANIA APPLICANTS:
AN* P$@!8N 3.8 DN83%NBE* AN0 3%#. %N#$N# #8 0$6@A?0 AN* %N!?@AN"$ "8PAN* 8@ 8#.$@
P$@!8N 6%E$! AN APPE%"A#%8N 68@ %N!?@AN"$ 8@ !#A#$$N# 86 "EA% "8N#A%N%NB AN* A#$@%AEE*
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NOTICE TO R'ODE ISLAND APPLICANTS:
AN* P$@!8N 3.8 DN83%NBE* P@$!$N#! A 6AE!$ 8@ 6@A?0?E$N# "EA% 68@ PA*$N# 86 A E8!! 8@
A$N$6%# 8@ DN83%NBE* P@$!$N#! 6AE!$ %N68@A#%8N %N AN APPE%"A#%8N 68@ %N!?@AN"$ %! B?%E#* 86
A "@%$ AN0 A* A$ !?AF$"# #8 6%N$! AN0 "8N6%N$$N# %N P@%!8N.
S!RPL!S LINES NOTICE OR R'ODE ISLAND APPLICANTS:
#.%! %N!?@AN"$ "8N#@A"# .A! A$$N PEA"$0 3%#. AN %N!?@$@ N8# E%"$N!$0 #8 08 A?!%N$!! %N #.$
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S!RPL!S LINES NOTICE OR SO!T' CAROLINA APPLICANTS:
#.%! "8PAN* .A! A$$N APP@8G$0 A* #.$ 0%@$"#8@ 8@ .%! 0$!%BN$$ 86 #.$ !8?#. "A@8E%NA
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A?# %# %! N8# A668@0$0 B?A@AN#* 6?N0 P@8#$"#%8N.
NOTICE TO TENNESSEE, (IR)INIA AND $AS'IN)TON APPLICANTS:
%# %! A "@%$ #8 DN83%NBE* P@8G%0$ 6AE!$+ %N"8PE$#$ 8@ %!E$A0%NB %N68@A#%8N #8 AN
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