Insuring E-Business E-Risk Security Protection 8040 W. Hwy. 50 - Salida, Colorado, 81201 (719)539-0144 - (800)571-2026 - Fax (719)539-4696 Please Feel Free to Contact Us, Should You Have Any Questions.
		Application for an E-Risk Protection Policy
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Applicant
Web Address
Principal City & State
Effective Date
In the Aggregate Limit of Liability of	$
	Please Complete the Following to Indicate the Amounts of Coverages Desired:
Insuring Agreement	Single Loss Limit	Deductible
Business Income Loss	$	$
Intellectual Property	$	$
Public Relations Expenses	$	$
Interruption of Service Liability	$	$
Electronic Publishing Liability	$	$
Computer Theft	$	$
E-Business Extortion	$	$

Please Check the Following to Indicate the Applicant's E-Business Activities:

E-Business Activity	Via the Internet	Via Private/Closed Network	Current Annual Revenues	Projected Revenues Next Fiscal Year
Electronic Commerce
E-Mail
Electronic Publishing
Employee Remote Access
Employee Web Access
Customer Account Access
Hosting for Others
Internet Service Provider
Collaboration
Data Processing for Others
Other(Please Specify)

If the Applicant Plans to Enter Into Ant of the Above Listed Activities During the Policy Period, Please List Such Activities Including Timing and Planned Extent of Involvement

If Business Income Loss Coverage is Requested, Please indicate the Average Hourly Business Income
The Applicant Has Been in Business Since
If Less Than Five Years, List Resumes of Founders and Senior Management
Who is the Chief Information Officer?
Contact Name for Risk Survey
Phone Number
Business and Customer Base
List All Subsidiaries and Describe Their Operations
Total Revenues From Most Recent Fiscal Year
What Percentage of Your Revenues are Derived From:
Internet (e-commerce) Activities
Retail Stores
Telemarketing
Fax
Mail and Other Sources

Complete the Following Regarding the Computer Systems Used by the Applicant

Does the Applicant Have an Enterprise Resource Planning System	yes	no	If Yes, Give Details on When System Was Adopted and Whose System is Being Used
Does the Applicant Use the Computer System of Others	yes	no	If Yes, List Systems, Services Provided, and Date Each Was Adopted
Does the Applicant Use the Services of Software Vendors	yes	no	If Yes, List Vendors and Services Provided
Has There Been Any Change in Ownership or Senior Management in the Past Three Years	yes	no	If Yes, Provide Details
Has There Been Any Change in the Applicant's Systems/Technology Senior Management in the Past Three Years	yes	no	If Yes, Provide Details
Does the Applicant Have a Full-Time. Dedicated Information Technology Security Professional	yes	no	If Yes, Provide Resumes on Such Professionals
Does the Applicant Have Written Policies and Procedures Established Addressing Actions to be Taken in the Event of an Extortion Demand	yes	no	If No, Provide a Proposed Implementation Date of Such Policies and Procedures
Has the Applicant Suffered Any Loss in Excess of $100,000.00 That Would be Payable Under a Commercial Crime or Dishonesty Bond/Policy or Computer Crime Policy, or Sustained Any Loss Under Any Insurance Similar to the Kinds Provided Under This Policy During the Last Three Years	yes	no	If Yes, Provide Details, IncludingAmount of Loss, Type of Coverage Involved, and Corrective Action Taken
List All Incidents Involving Loss of Service, Except for Planned Maintainance, of Computer Systems Exceeding Four Hours in the Last Three Years, Including the Time Out of Service, an Estimate of Costs to Restore Service, Estimate of Income Lost, Causeof Disruption, and Corrective Actions Taken
Has Any Insurance Similar to the Kinds Provided Under This Policy, Been Declined or Canceled During the Last Three Years?(Not Applicable in Missouri)	yes	no	If Yes, Provide Details

Please Provide the Following:
	The Most Recent Annual Report, or Audited Financial Statements With All Notes and Schedules if no Annual Report is Prepared
	The Most Recent CPA Management Letter or Director's Examination and Response to Recommendations Made Therein
	The Most Recent Audit or Examination of the IS/IT Department
	A List of All Material Litigation Threatened or Pending Against the Applicant
	A List of All Subsidiaries Proposed for This Insurance . Including Name, Nature of Business, Date of Incorporation, Name of Parent, Percent of Ownership, Domestic or Foreign, and Date of Acquisition for Each
	The Applicant Represents That the Information Furnished in This Application is Complete, True, and Correct. Any Misrepresentation Omission, Concealment, or Incorrect Statement Shall Be Grounds for the Recission of Any Policy Issued in Reliance Upon Such Information. The Submission of This Application Does Not Bind the Insurance Company to Sell nor the Applicant to Purchase the Insurance. However, it is Agreed that this Application and any Documents or Information Submitted Herewith Shall be the Basis of the Contract Should a Policy be Issued and that it Will be Attached to and Made a Part of the Policy.
Agreed	Date
Applicant
Title

When obtaining information from you, we adhere to a simple, commonsense principle: we ask for only the information we need to provide for the service you've requested.

You can be assured that your name and address never leave our site and records at GKS Insurance. If you purchase a product from us, we won't pass your name to someone else or some other company in order for them to sell you additional products. We will only share your information to sureties and parties processing your policies or bonds.

We are in the commercial insurance and surety bond business, not the marketing business.

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