Insurance National Security Application

INSURANCE NATIONAL SECURITY APPLICATION

A. Applicant / Insured Information

Applicant Name:

B. Entity Type and Classification

Please indicate entity type (check all that apply):

Individual

Corporation

Limited Liability Company (LLC)

Government Contractor

Foreign-owned or Controlled Entity

C. Policy Details Requested

D. Coverage Options (select requested coverages)

Indicate which coverages are requested. Coverage is subject to underwriting review and specific terms, conditions, and exclusions.

Terrorism and Sabotage

Political Violence and Civil Commotion

Cyber Espionage and Data Compromise

Breach of Classified or Controlled Information

Supply Chain Interruption (including foreign suppliers)

Loss Arising from Export Control Violations

Third-Party Liability for National Security Claims

Business Interruption Due to National Security Events

E. National Security Questionnaire

The following questions relate to activities and relationships relevant to national security underwriting. Answer honestly; material misstatement may void coverage.

1. Does the applicant perform work under classified or controlled contracts?   Yes No

2. Is the applicant owned, controlled by, or affiliated with a foreign government or foreign principal?   Yes No

3. Does the applicant access, store, or transmit export-controlled technology or information?   Yes No

4. Has the applicant experienced a cyber incident, data breach, or compromise affecting classified or regulated data within the past 5 years?   Yes No

F. Risk Profile and Operations

G. Exclusions and Acknowledgements

The applicant acknowledges that coverage, if issued, will be subject to specific exclusions. Applicant understands and acknowledges the following common exclusions may apply and certifies awareness of each item checked.

Acts of war or declared hostilities

Intentional wrongdoing, fraud, or criminal acts by insured principals

Nuclear, chemical, or radiological hazards

Losses arising from violation of sanctions or prohibitions on trade with specified entities

Liability assumed under contract beyond insured's legal obligations

H. Beneficiary Designation (if applicable)

Provide beneficiary information where coverage contemplates payable benefits on death or similar events.

I. Prior Losses and Claims

Yes No

J. Declarations, Authorizations and Certification

By signing below, the applicant certifies that the information provided in this application is true, complete and correct to the best of the applicant's knowledge. The applicant acknowledges that the insurer will rely upon these statements in underwriting and that material misrepresentation, omission, or concealment of relevant facts may result in rescission of coverage or denial of claims.

The applicant authorizes the insurer to obtain and verify information from third parties, including but not limited to background checks, claims history, public records, and security clearance status as necessary for underwriting and claims handling. The applicant agrees to cooperate with reasonable security and due diligence procedures and to notify the insurer promptly of any material change in security posture, foreign relationships, or contractual obligations that may affect risk.

The applicant further acknowledges that coverage may be conditioned on compliance with export control, sanctions, and other national security laws and regulations, and that failure to comply with such laws may void coverage for related losses.

I attest under penalty of perjury that the foregoing is true and correct:

Applicant acknowledges representation and consenting declarations above

Sign Now