Insurance ML Proposal

INSURANCE ML PROPOSAL

Applicant / Insured Information

Client Name:

Individual Corporation LLC Partnership Other:

Policy Details

Policy Type(s): Professional Liability Technology E&O Cyber Liability IP / Media Liability Other:

Model & Operational Information

Model Stage: Development Testing Production Number of Active Endpoints:

Deployment, Controls & Risk Mitigation

Deployment Environment: Cloud On-premises Hybrid

Access Controls / Role-Based Access Encryption (in transit / at rest) Data Anonymization / Pseudonymization Explainability / Feature Attribution Adversarial Testing / Robustness Checks Incident Response Plan

Claims, Loss History & Known Issues

Have there been any incidents, claims, regulatory investigations or material losses related to the model or related services in the past 5 years? Yes No

Coverage Options & Requested Endorsements

Select coverage components requested: Liability for Model Outputs Data Breach Response & Liability Regulatory Fines & Investigations Contractual Liability (where insurable) Product Liability Media / IP Liability

Exclusions / Acknowledgements

The undersigned acknowledges that, if issued, the policy will contain standard exclusions including but not limited to: intentional wrongdoing, fraud, bodily injury and property damage covered under general liability, war and nuclear hazards, prior known circumstances not disclosed on this proposal, and punitive damages where unenforceable by law. The insurer's obligation to provide coverage is subject to the policy's insuring agreements, conditions and exclusions.

Beneficiary Designation

(Complete if applicable to requested coverage)

Attachments & Documentation Checklist

Please indicate which documents are attached to this proposal:

Model technical documentation Dataset inventory / lineage Risk assessment / impact analysis Incident response plan Prior claim documentation

Declarations, Representations & Certification

The undersigned hereby declares that the information provided in this proposal and in any attachments is true, complete and accurate to the best of the applicant's knowledge and belief. The applicant acknowledges that this proposal, any supporting documentation and any statements made in connection with this proposal shall form the basis of any policy issued and that coverage shall be subject to all terms, conditions, limitations and exclusions contained in the policy.

The applicant further represents and warrants that the applicant will notify the insurer promptly of any material change in the exposures described in this proposal, including but not limited to changes in deployment, significant model architecture modifications, material changes in data sources, or any incident that may give rise to a claim. Failure to disclose material information or a material misrepresentation may be grounds for declination, cancellation, or rescission of coverage.

The applicant authorizes the insurer and its representatives to make any inquiries for underwriting purposes, including requests for detailed documentation, verification of prior loss history and review of operational controls. This proposal is an application for insurance only and does not bind the insurer to provide coverage nor bind the applicant to accept coverage, unless and until a policy is issued and a premium is paid in accordance with an agreement executed by an authorized representative of the insurer.

The applicant understands that coverage, if issued, may include sublimits, waiting periods, and territory limitations. The applicant agrees to cooperate with underwriting and claims investigation, to provide truthful responses, and to comply with the notice and cooperation provisions in any resulting policy.

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