FCCL -CRNASUPP 07161
CYBER RISK - NETWORK SHARING AGREEMENTSUPPLEMENTAL APPLICATIONNOTE: / All questions must be completed
Please attach a copy of your contract for review
CLIENT INFORMATION
Cyber Policy # (if applicable)
Legal Name of Applicant
Key Contact / Position
Mailing Address / Postal Code
Phone / Fax
Email / Website
Key Broker Contact
Brokerage Name
Brokerage Address / Postal Code
Phone / Fax
Email / Website
GENERAL INFORMATION
What is the extent of involvement your organization has in terms of using the data?
(E.g. are you only allowed to input data, can you manipulate the data that is stored in the system?)
Please provide full details
Indicate the type of data that is held on the shared system
Please provide full details
Is the contract clear as to where your liability for the data begins and ends and where the liability of the Shared
Network Providers liability begins and ends?
(e.g. if there is an issue with the database such as information is lost or stolen and it is proven that the Network Service
Provider is at fault will any liability fall on your organization?) / YES / NO
Please provide full details
NETWORK SYSTEM – I.T. DESIGN AND MANAGEMENT QUESTIONS
Who is actually designing and operating the Shared Network System on an on-going basis?
Please provide full details
Does the Network Service Provider have a Technology Errors & Omissions policy in place? / YES / NO
Carrier / Policy Number / Limit of Insurance / $
Indicate the Security and I.T. Risk Management measures that are in place for the Shared System. Please include the
details as to the type of security and the frequency of security testing being carried out
Please provide full details
Provide full details regarding the Disaster Recovery and Business Continuity Planning that is in place for this System
Please provide full details
APPLICANT ACKNOWLEDGEMENT
The Applicant hereby represents after inquiry, that information contained herein and in any supplemental applications or forms required
hereby, is true, accurate and complete, and that no material facts have been suppressed or misstated. The Applicant acknowledges a
continuing obligation to report to the Company as soon as practicable any material changes in all such information, after signing the
application and prior to issuance of the policy, and acknowledges that the Company shall have the right to withdraw or modify any
outstanding quotations and/or authorization or agreement to bind the insurance based upon such changes.
If a policy is issued, the Company will have relied upon, as representations, this application, any supplemental applications, and any
other statements furnished to the Company in conjunction with this application, all of which are hereby incorporated by reference into
this application and made a part thereof.
The undersigned, on behalf of the insured organization, acknowledges that any personal information provided in connection with this
application (including but not limited to the information contained in this form) has been collected in accordance with applicable
privacy legislation and this information shall only be used or shared by the Company to assess, underwrite and price insurance
products and related services, administer and service insurance policies, evaluate and investigate claims, detect and prevent
fraud, analyze and audit business results and/or comply with regulatory or legal requirements.
Applicant Name / Title/Position
Applicant Signature / Date
Broker Name
Broker Signature
FCCL -CRNASUPP 07161