APA Professional Liability

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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.

1. a) Name of Applicant *

b) FULL Address of Practice (include City, State and Zip Code) *

Telephone Number

Fax Number

Email Address

FULL Mailing Address (include City, State and Zip Code)

Form of Practice

Sole Proprietor

Partnership

Corporation

2. Check if Applicant is:

# of Police Polygraph Exams

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

% full-time employment

% part-time private practice

4.

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

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

5. What percentage of the Applicant’s polygraph exams are sex offender testing?

Give details of any particular training or qualifications in respect of sex offender testing that the Applicant has

0/550 characters

6. Does the Applicant provide polygraph services for tournaments or contests?

Yes

No

If Yes, please provide details about such tournaments or contests, and specify the approximate number of such events for which the Applicant provides polygraph services each year. Also, please attach or otherwise provide: (1) any tournament or contest rules; (2) any tournament or contest application form that is signed by participants; and (3) any contract between the Applicant and the sponsor of the tournament or contest.

0/550 characters

7. Does the Applicant provide, or intend to provide, polygraph services for television programs?

Yes

No

If Yes, please provide details about such programs. Also, please attach or otherwise provide: (1) the Applicant’s contract with the television network or program producer; (2) any indemnification or hold-harmless agreement between the Applicant and the television network or program producer; (3) any contract, waiver, or release form signed by the contestants on the television program.

0/550 characters

8. Please give a detailed description of interviewing

0/550 characters

9a) Does the Applicant conduct background investigations?

Yes

No

b) Is the information that the Applicant collects a matter of public record?

Yes

No

If no, please provide a description of this type of work (use a separate sheet if necessary).

0/550 characters

10. Does the Applicant videotape the polygraph exams?

Yes

No

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?

Yes

No

If yes, please give details

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?

Yes

No

If yes, please give details

0/370 characters

13. Is the Applicant aware of any circumstances which may result in any claim being made against the Applicant

Yes

No

If yes, please give details

0/370 characters

14. Has any similar insurance for the Applicant ever been declined or cancelled?

Yes

No

If yes, please give details

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

See your files

Insurer 🛈

Amount of Policy

Whether "Claims Made" or "Occurrence" Coverage

Policy Period (eff to exp dates):

Deductible

Premium

16. Please check Appropriate box(es) for limits of liability you require.

B) Please provide a quote for Contingent Bodily Injury

Yes

No

17 A) I am currently a member in good standing of the American Polygraph Association:

Yes

No

B) I hold a “Certificate of Advanced & Specialized Training” with the APA:

Yes

No

Private Investigators Section

	Enter percentages of each Activity. (100% Total)
Alarm Installation, Services or Repair	Enter percentages of each Activity. (100% Total)
Asset Searches	Enter percentages of each Activity. (100% Total)
Arson Investigation	Enter percentages of each Activity. (100% Total)
Bail Bond Operations	Enter percentages of each Activity. (100% Total)
Bodyguards	Enter percentages of each Activity. (100% Total)
Bounty Hunters	Enter percentages of each Activity. (100% Total)
Computer Fraud	Enter percentages of each Activity. (100% Total)
Corporate-Employee Dishonesty	Enter percentages of each Activity. (100% Total)
Credit Pre-Employment Screening	Enter percentages of each Activity. (100% Total)
Drug Surveillance	Enter percentages of each Activity. (100% Total)
Drug Testing	Enter percentages of each Activity. (100% Total)
Formal Signed Statements	Enter percentages of each Activity. (100% Total)
Guard Services	Enter percentages of each Activity. (100% Total)
Insurance Claim Investigation	Enter percentages of each Activity. (100% Total)
Legal	Enter percentages of each Activity. (100% Total)
Motor Vehicle Accidents & Reconstruction	Enter percentages of each Activity. (100% Total)
Motor Vehicle Reconstruction	Enter percentages of each Activity. (100% Total)
Process Servers	Enter percentages of each Activity. (100% Total)
Process Service	Enter percentages of each Activity. (100% Total)
Quiet Title	Enter percentages of each Activity. (100% Total)
Reposition/Collection Work	Enter percentages of each Activity. (100% Total)
Records Check	Enter percentages of each Activity. (100% Total)
Slip & Fall Accidents	Enter percentages of each Activity. (100% Total)
Security Consulting	Enter percentages of each Activity. (100% Total)
Undercover Operations	Enter percentages of each Activity. (100% Total)
Surveillance (describe below)	Enter percentages of each Activity. (100% Total)
Other (describe below)	Enter percentages of each Activity. (100% Total)

Surveillance - Describe

Other - Describe

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.

Name of person completing the application *

/s/ Electronic Signature *

Title

Date Signed * +

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?

Yes

No

If YES, please provide details including how remote access is restricted? Use a separate attachment if necessary.

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?

Yes

No

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?

Yes

No

4. Does applicant use intrusion detection software to detect unauthorized access to internal networks and computer systems?

Yes

No

5. Does applicant use firewall protection and anti-virus systems to prevent unauthorized access to internal networks and computer systems?

Yes

No

6. How does applicant limit access to its internal networks, computer systems and electronic devices (i.e. passwords, encryption or both)?

7. How does applicant ensure sensitive data is permanently removed before any computer equipment or paper file is discarded?

8. Does applicant accept payment by credit card?

Yes

No

If YES, is that information stored on your network?

Yes

No

9. Does applicant have a written procedure to communicate a privacy breach to state authorities and affected parties?

Yes

No

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)

Yes

No

If YES, please provide details. Use a separate attachment if necessary.

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?

Yes

No

If YES, please provide details. Use a separate attachment if necessary.

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?

Yes

No

If YES, please provide details. Use a separate attachment if necessary.

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)

Own Personnel/Staff paper record:

Own Personnel/Staff electronic record:

Clients/Other paper record:

Clients/Other electronic 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.