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APPLICATION FOR
PROFESSIONAL LIABILITY INSURANCE
issued to the
AMERICAN POLYGRAPH ASSOCIATION
(This is an application for a Claims Made Coverage)
 

A) Please answer all questions, leaving no blank spaces.
B) The application must be signed and dated.
C) When answering questions, please use a separate attachment if space provided is insufficient.
D) You must be a member of the American Polygraph Association.
Form of Practice
2. Check if Applicant is:
 

3. If the Applicant has checked b), c) or e) above and ALSO maintains a part-time private polygraphist practice, indicate the percentage of time devoted to

4.
 Number of cases handled in past 12 monthsGross income from the past 12 monthsNumber of cases expected to be handled in the next 12 monthsGross income expected from those services in the next 12 months
Private Practice Polygraph
Written Testing
Interviewing
Background Checks
*Private Investigation
Ocular-Motor Detection Tests

* If this work is undertaken, please complete the Private Investigators Section on the last page.

0/550 characters
6. Does the Applicant provide polygraph services for tournaments or contests?
0/550 characters
7. Does the Applicant provide, or intend to provide, polygraph services for television programs?
0/550 characters
0/550 characters
9a) Does the Applicant conduct background investigations?
b) Is the information that the Applicant collects a matter of public record?
0/550 characters
10. Does the Applicant videotape the polygraph exams?
11. Has the Applicant ever been subject to any disciplinary proceedings or reprimanded by or refused admission to practice or suspended from practice before any court or administrative agency?
0/550 characters
12. Have any claims or suits been made during the past five years against the Applicant either as an individual or as an employee of a police department or private polygraph firm?
0/370 characters
13. Is the Applicant aware of any circumstances which may result in any claim being made against the Applicant
0/370 characters
14. Has any similar insurance for the Applicant ever been declined or cancelled?
0/370 characters
15. Please give full particulars of all Polygraph Insurance carried during the past five years.
If this is a renewal check here
16. Please check Appropriate box(es) for limits of liability you require.
B) Please provide a quote for Contingent Bodily Injury
17 A) I am currently a member in good standing of the American Polygraph Association:
B) I hold a “Certificate of Advanced & Specialized Training” with the APA:
Private Investigators Section 
0/100 points

I hereby declare that the above statements and particulars are true, and that I have not suppressed or misstated any material facts.  At the present time, I have no reason to anticipate any claim being brought against me for any act, error, or omission on my part, other than as stated above, and agree that this Proposal Form shall be the basis of the contract between me and the Underwriters and shall be deemed a part thereof.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

 

Pursuant to the provisions of the Electronic Signatures in Global and National Commerce Act (E-SIGN, 2000) execution of the application form by means of typing ones name, title and date below carries the same weight and legal effect as traditional paper documents and handwritten signatures.  Further, as a principal of Applicant, I confirm that I have authority to execute this application on behalf of Applicant.

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A signed copy will be attached to and form part of the Policy or Endorsement/Certificate, if issued.  Completion of this Proposal Form does not bind or obligate the Applicant to complete this insurance.

Data Security Breach and Client Network Infection Questionnaire

1. Does the applicant provide remote access to its internal networks and computer systems?
2. Are there formalized security policies for anyone with direct or remote access to your hard wired or wireless network or paper files and records?
3. Do you comply with all applicable regulatory and industry supported privacy and security standards and frameworks that are applicable to your industry, including PCI data to your business?
4. Does applicant use intrusion detection software to detect unauthorized access to internal networks and computer systems?
5. Does applicant use firewall protection and anti-virus systems to prevent unauthorized access to internal networks and computer systems?
8. Does applicant accept payment by credit card?
If YES, is that information stored on your network?
9. Does applicant have a written procedure to communicate a privacy breach to state authorities and affected parties?
10. Does confidential data ever leave the applicant’s premises by way of paper or electronic format? (This includes any outsourced data handling/data processing / offsite storage)
11. Has the applicant had any incidents, claims, suits or complaints involving unauthorized access, breach, misuse or compromise of any system of maintaining storage of confidential client or employee information?
12. Is the applicant aware of any incident which could give rise to a claim, suit or complaint involving unauthorized access, breach, misuse or compromise of any system of maintaining storage of confidential client or employee information?
13. Please provide below the approximate number of computer and paper records (in office and in storage) kept regarding individuals: 

(One client or personnel/staff equals one record)

I/We have not suppressed or misstated any material facts. 

I/We agree that this application shall be the basis of the contract with the insurers.

Signing this application does not bind the applicant or the Insurers to complete the insurance, but it is agreed that this application shall be the basis thereof.

 

Pursuant to the provisions of the Electronic Signatures in Global and National Commerce Act (E-SIGN, 2000) execution of the application form by means of typing ones name, title and date below carries the same weight and legal effect as traditional paper documents and handwritten signatures.  Further, as a principal of Applicant, I confirm that I have authority to execute this application on behalf of Applicant.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

 
Please fill out form and click the SUBMIT BUTTON at the bottom of the form. 
You will have a chance to save a copy for your records.