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Tech E amp O Cyber And Privacy Insurance Chubb in the US
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1 Applicant Information,Desired Effective Date,Mm dd yyyy. Applicant Name,Click here to enter text,Applicant Address City State Zip. Click here to enter text,Officer Name Title,Click here to enter text Click here to enter text. Email Address Phone Number,Click here to enter text Click here to enter text. Please list all Subsidiaries for which coverage is desired. Click here to enter text,Applicant Type Primary Industry.
Choose an item Choose an item,Year Established Total Number of Employees. Click here to enter text Enter a number or choose an item. Global Revenue Prior Fiscal Year Online Revenue Prior Fiscal Year. Click here to enter text Click here to enter text, Global Revenue Current Fiscal Year Online Revenue Current Fiscal Year. Click here to enter text Click here to enter text, Primary Company Website s Operates outside of the United States. Click here to enter text Choose an item, 2 Desired Coverage Only enter information for desired coverages. Retention Aggregate Per Claim or Other Options,Limit Incident.
Policy Level Limits Protected Information,Coinsurance. Choose an item,Technology Errors and Omissions, Cyber Incident Response Fund Non Panel Vendor Sublimit. Side Car Option,Choose an item, Business Interruption Loss and Extra Waiting Period. Expense of hours, Contingent Business Interruption Loss Waiting Period. and Extra Expense of hours,Digital Data Recovery,Network Extortion.
Cyber Privacy and Network Security Payment Card Loss Limit. Regulatory Proceedings, Electronic Social and Printed Media Coverage Scope Option. PF 48404 10 16 2,Liability Choose an item,Cyber Crime Computer Fraud. Cyber Crime Funds Transfer Fraud,Cyber Crime Social Engineering Fraud. Enter any further commentary about desired coverages. Click here to enter text,3 Nature of Operations,Class of Business. Describe nature of business operations products or services in layperson terms. Please indicate the applicable percentage of total revenue derived from each product or. service offered,Type of Product or Service Current Revenues.
Application Service Provider Click here to enter text. Bulletin Board System Forum Sites Click here to enter text. Billing Services Click here to enter text,Computer Aided Design Click here to enter text. Collocation Facilities Click here to enter text,Credit Card Processing Click here to enter text. CRM Consulting Click here to enter text,Data Entry Timesharing Click here to enter text. Data Processing Click here to enter text,E Commerce Consulting Click here to enter text. ERP Consulting Click here to enter text,Graphic Design Click here to enter text.
Hardware Assembly Click here to enter text,Hardware Manufacturing Click here to enter text. Healthcare Click here to enter text, Infrastructure Equipment Manufacturing Click here to enter text. Infrastructure Software Click here to enter text,Internet Advertising Click here to enter text. Internet Service Provider Click here to enter text. Manufacturing Click here to enter text,Messaging Services Click here to enter text. Online Banking Click here to enter text,Online Brokerage Click here to enter text.
Online Exchanges Click here to enter text,Portals Click here to enter text. Retail E Commerce Click here to enter text,Security Consulting Click here to enter text. Security Software Click here to enter text,Software Development Click here to enter text. Software Installation Custom Click here to enter text. Software Installation Pre packaged Click here to enter text. Specialty Programming Click here to enter text,Systems Analysis Click here to enter text. PF 48404 10 16 3,Systems Engineering Click here to enter text.
Systems Integration Click here to enter text,Systems Maintenance Click here to enter text. Technical Research Click here to enter text,Technical Support Click here to enter text. Technical Training Click here to enter text,Telecommunication Click here to enter text. Value Added Reselling Click here to enter text, Video Conferencing Services Click here to enter text. Web Hosting Click here to enter text,Web Maintenance Services Click here to enter text.
Other Please Explain Click here to enter text, Does the Applicant have any products or services entering new markets or territories within the next year that are. substantially different in scope or end use than current products or services including as a result of recent or. planned merger or acquisition,If Yes please provide details. Click here to enter text, Does the Applicant currently or will the Applicant potentially operate as a financial institution cryptocurrency. exchange third party claims administrator accreditation service media production company payment processor. data aggregator broker warehouse credit bureau direct marketer intellectual property registration or legal. services video game developer mobile application developer social media peer to peer file sharing computer. automated design or engineering gambling services provider adult content provider or a provider of any. component product software or services related to aviation medical transportation surveillance data security or. life safety Or does the Applicant derive more than 50 of its revenue from non technology products and services. e g software electronics telecom,If Yes please provide details. Click here to enter text, 4 Technology E O Only if applying for this coverage.
a What is the size of the Applicant s largest active customer contract in terms of annual revenue. Client Nature of Contract Service Contract,Value Duration. b What is the Applicant s average contract value Click here to enter text. c What is the Applicant s average contract length in months Click here to enter text. d From what percentage of customers does the Applicant obtain written contracts Choose an item. purchase orders or user acceptance agreements,PF 48404 10 16 4. e From what percentage of vendors does the Applicant obtain written contracts Choose an item. purchase orders or user acceptance agreements, f Does qualified legal counsel review all of the Applicant s critical contracts such as Yes No. critical vendor contracts boilerplate standard customer contracts and any. substantially customized or deviated contracts for larger customers. g What percent of the Applicant s customer contracts purchase orders or user agreements contain. 1 Specific descriptions of the professional services being provided Choose an item. 2 A limitation of liabilities to cost of products or services or some dollar Choose an item. 3 A warranty disclaimer Choose an item, 4 Hold harmelss or indemnity agreements inuring to the benefit of the Choose an item. 5 Hold harmelss or indemnity agreements inuring to the benefit of customers Choose an item. 6 Formalized change order processes requiring signoff by both parties Choose an item. 7 Conditions of customer acceptance of products services Choose an item. 8 Acceptance of consequential damages Choose an item. 9 Provisions for liquidated damages Choose an item. 10 Provisions for the ownership of intellectual property Choose an item. h Does the applicant guarantee systems or website availability Yes No. if yes describe in attachment,Independent Contractors.
i If the Applicant uses independent contractors and or subcontractors. 11 What percentage of the Applicant s revenue is derived from work Click here to enter. subcontracted to others text, 12 Does the applicant always use a written contract upon engagement of Yes No. contractor, 13 Does the Applicant require that subcontractors carry professional liability or Yes No. Technology E O insurance with liability limits of at least 1 000 000. 14 Does the Applicant obtain written contracts from subcontractors containing Yes No. indemnification or hold harmless agreements in favor of the Applicant. 15 Do all contracts with independent contractors clearly identify work product Yes No. as work made for hire or include other provisions for the ownership of. intellectual property,Government Related Work, j Does the applicant have procedures to ensure compliance with Federal State and. local statutes Yes No, k What percent of the Applicant s revenues come from Click here to enter. 1 Work for Municipal or State governments text, 2 Work for the Federal Government of the United States of America Click here to enter.
l If the Applicant generates more than 50 of gross revenues from the U S Federal. Government, 1 Does the Applicant operate as a prime contractor or sub to prime contractor Choose an item. PF 48404 10 16 5, 2 Does the Applicant primarily use Federal Acquisition Regulation FAR Yes No. contracts or ensure that FAR flow down provisions are within the contracts. entered by the Applicant,Quality Control, m Does the Applicant have formal customer acceptance milestone management and Yes No. customer signoff procedures in place including obtaining final acceptance letters. n Does the Applicant have a process in place to handle and resolve client Yes No. complaints, o Does the Applicant have a written and formalized quality control program Yes No. including software development methodologies if applicable. p Does the Applicant have vendor certification guidelines in place Yes No. 5 Information Privacy and Governance, Which of the following types of Privacy Information Personal Information or Third Party Corporate Information does.
the Applicant store process transmit or otherwise have responsibility for securing Please indicate total number of. records if known inclusive of both internal or third parties. a Government issued identification numbers e g Social Security numbers Yes No of records. b Credit card numbers debit card numbers or other financial account numbers Yes No of records. c Healthcare or medical records Yes No of records, d Intellectual property e g third party intellectual property trade secrets M A Yes No of records. information,e User names and passwords Yes No of records. f Does the Applicant maintain a data classification and data governance policy Yes No. g Does the Applicant maintain documentation that clearly identifies the storage and transmission Yes No. of all Privacy Information, h When was the Applicant s privacy policy last reviewed mm yyyy. i Do you provide adequate notice to individuals e g customers consumers of any Yes No. private personal information that is being collected and or shared. j Optional Additional comments regarding Information Privacy and Governance. Click here to enter text, Which of the following statements are valid as it relates to Privacy Information governance Use the comments. section for clarification as needed, k Does the Applicant encrypt Privacy Information when.
i Transmitted over public networks e g the Internet Yes No. ii Stored on mobile assets e g laptops phones tablets flash drives Yes No. iii Stored on enterprise assets e g databases file shares backups Yes No. iv Stored with third party services e g cloud provider Yes No. l Does the Applicant store Privacy Information on a secure network zone that is segmented from Yes No. the internal network, Optional What other technologies are used to secure Privacy Information e g tokenization. Click here to enter text, m Optional Additional comments regarding Information Privacy and Governance. Click here to enter text,PF 48404 10 16 6,6 Information Security Organization. a Does the Applicant have an individual designated for overseeing information security Yes No. Enter name and title, b Does the Applicant have an individual designated for overseeing information privacy Yes No. Enter name and title, c Is the Applicant compliant with any of the following regulatory or compliance frameworks please check all that.
apply and indicate most recent date of compliance, ISO1799 as of date HITECH as of date SSAE 16 as of date. SOX as of date HIPAA as of date FISMA as of date, PCI DSS as of date GLBA as of date Other as of date. d Does the Applicant leverage any industry security frameworks for confidentiality integrity and availability e g. NIST COBIT, e Is the Applicant an active member in outside security or privacy groups e g ISAC IAPP ISACA. Yes No Comments, f Optional What percentage of the overall IT budget is allocated for security. g Optional Additional comments regarding the Information Security Organization. 7 Information Security, q Does the Applicant have a formal risk assessment process that identifies critical assets threats Yes No.
and vulnerabilities, r Does the Applicant have a disaster recovery and business continuity plan Yes No. s Does the Applicant have an incident response plan for determining the severity of a potential Yes No. data security breach and providing prompt notification to all individuals who may be adversely. affected by such exposure, t Does the Applicant have an intrusion detection solution that detects and alerts an individual or Yes No. group responsible for reviewing malicious activity on the Applicant s network. u Does the Applicant configure firewalls to restrict inbound and outbound network traffic to Yes No. prevent unauthorized access to internal networks, v Does the Applicant perform reviews at least annually of the Applicant s third party service Yes No. providers to ensure they adhere to the Applicant s requirements for data protection. w Does the Applicant use multi factor authentication for remote network access originating from Yes No. outside the Applicant s network by employees and third parties e g VPN remote desktop. x Does the Applicant conduct security vulnerability assessments to identify and remediate Yes No. critical security vulnerabilities on the internal network and Applicant s public website s on the. y Does the Applicant install and update an anti malware solution on all systems commonly Yes No. affected by malicious software particularly personal computers and servers. PF 48404 10 16 7, z Does the Applicant use any software or hardware that has been officially retired i e considered Yes No. end of life by the manufacturer e g Windows XP,List software.
aa Does the Applicant update e g patch upgrade commercial software for known security Yes No. vulnerabilities per the manufacturer s advice, bb Does the Applicant update open source software e g Java Linux PHP Python OpenSSL that Yes No. is not commercially supported for known security vulnerabilities. cc Does the Applicant have processes established that ensure the proper addition deletion and Yes No. modification of user accounts and associated access rights. dd Does the Applicant enforce passwords that are at least seven characters and contain both Yes No. numeric and alphabetic characters, ee Does the Applicant require annual security awareness training for all personnel so they are Yes No. aware of their responsibilities for protecting company information and systems. ff Does the Applicant screen potential personnel prior to hire e g background checks including Yes No. previous employment history drug screen criminal record credit history and reference. gg Does the Applicant have a solution to protect mobile devices e g laptops smartphones Yes No. tablets to prevent unauthorized access in the event the device is lost or stolen. hh Does the Applicant have entry controls that limit and monitor physical access to company Yes No. facilities e g offices data centers, 8 Third Party Technology Services e g cloud web hosting co location managed services. a Is there an individual responsible for the security of the Applicant s information that resides at Yes No. third party technology service providers, b Do the Applicant s third party technology service providers meet required regulatory Yes No. requirements that are required by the Applicant e g PCI DSS HIPAA SOX. c Does the Applicant perform assessments or audits to ensure third party technology providers Yes No. meet the Applicant s security requirements, If Yes when was the last audit completed As of date.
d Does the Applicant have a formal process for reviewing and approving contracts with third Yes No. party technology service providers, e Optional Additional comments regarding Third Party Technology Services. PF 48404 10 16 8, 9 Current Network and Technology Providers if applicable required at the time of binding. Internet Communication Services Credit Card Processor s. Enter Provider s Enter Provider s, Website Hosting Other Providers e g Human Resource Point of Sale. Enter Provider s Enter Provider s,Collocation Services Anti Virus Software. Enter Provider s Enter Provider s,Managed Security Services Firewall Technology.
Enter Provider s Enter Provider s, Broadband ASP Services Intrusion Detection Software. Enter Provider s Enter Provider s, Outsourcing Services Cloud Services e g Amazon Salesforce Office365. Enter Provider s Enter Provider s, Please complete the following information for cloud providers who process or store Privacy Information for Applicant. Use the optional comments if more space is required. Cloud Provider Type Service of Records Encrypted Storage. Enter Provider Choose an item Choose an item of Records Choose an item. Enter Provider Choose an item Choose an item of Records Choose an item. Enter Provider Choose an item Choose an item of Records Choose an item. Optional Additional comments regarding Cloud Services. Click here to enter text, 10 Internet Media Information only required if Internet Media Coverage is being requested. a Please list the domain names for which coverage is requested. Click here to enter text, b Has legal counsel screened the use of all trademarks and service marks including Applicant s Yes No.
use of domain names and metatags to ensure they do not infringe on the intellectual property. rights of others, c Does Applicant obtain written permissions or releases from third party content providers and Yes No. contributors including freelancers independent contractors and other talent. d Does Applicant require indemnification or hold harmless agreements from third parties Yes No. including outside advertising or marketing agencies when Applicant contracts with them to. create or manage content on Applicant s behalf, e If Applicant sells advertising space on any of its websites are providers of advertisements Yes No. required to execute indemnification and hold harmless agreements in Applicant s favor. f Have Applicant s privacy policy terms of use terms of service and other customer policies Yes No. been reviewed by counsel, g Does Applicant involve legal counsel in reviewing content prior to publication or in evaluating Yes No. whether it should be removed when notified that content is defamatory infringing in violation. of a third party s privacy rights or otherwise improper. PF 48404 10 16 9, h Does Applicant s website s include content directed at children under the age of 18 Yes No. i Does Applicant collect data about children who use its website s Does Applicant obtain Yes No. parental consent regarding collection of data about children who use its website s. j Please describe the Applicant s process to review content prior to publication to avoid the posting publishing. or dissemination of content that is defamatory infringing in violation of a third party s privacy rights or. otherwise improper,Click here to enter text, k Please describe the Applicant s review and takedown procedure when notified that content is defamatory.
infringing in violation of a third party s privacy rights or otherwise improper. Click here to enter text, l Optional Additional comments regarding the Internet Media Information. Click here to enter text,11 Current Loss Information. In the past five years has the Applicant ever experienced any of the following events or incidents Please. check all that apply Please use the comments section below to describe any current losses. a Applicant was declined for Tech E O Privacy Cyber Network or similar in surance or had an Yes No. existing policy cancelled Missouri applicants do not answer this question. b Within the last three years has a customer claimed that they had a financial loss as a result of Yes No. an error or omission on the part of the Applicant, c Has the Applicant or any of its predecessors in business subsidiaries or affiliates or any of the Yes No. principals directors officers partners professional employees or independent contractors. ever been the subject of a disciplinary action as a result of professional activities. d Applicant its directors officers employees or any other person or entity proposed for Yes No. insurance has knowledge of any act error or omission which might give rise to a claim s. under the proposed policy, e Applicant has been the subject of an investigation or action by any regulatory or administrative Yes No. agency for violations arising out of Applicant s advertising or sales activities. f Applicant sustained a loss of revenue due to a systems intrusion denial of service tampering Yes No. malicious code attack or other type of cyber attack. g Applicant had portable media e g laptop backup tapes that was lost or stolen and was not Yes No. h Applicant had to notify customers or offer credit monitoring that their personal information Yes No. was or may have been compromised as a result of the Applicant s activities. i Applicant received a complaint concerning the content of the Applicant s website s or other Yes No. online services related to intellectual property infringement content offenses or advertising. j Applicant sustained an unscheduled network outage that lasted over 24 hours Yes No. k Optional Additional information regarding Current Loss Information. Click here to enter text,PF 48404 10 16 10,12 Current Coverage.
Which of the following policies does the Applicant currently have in force. General Liability Policy Cyber Privacy Liability Policy. D O Policy Crime, Professional Liability incl Tech E O Other Related Policy Please Specify. 13 Current Cove, ii If the Applicant currently purchases E O insurance to address the failure of their product or. service please provide,Coverage Description Click here to enter text. Carrier Click here to enter text,Limit of Insurance Click here to enter text. Deductible Click here to enter text,Premium Click here to enter text.
Expiration Date Click here to enter a date,Retro Date Click here to enter a date. jj If the Applicant currently purchases Cyber or Privacy Liability insurance. If Yes please provide,Coverage Description Click here to enter text. Carrier Click here to enter text,Limit of Insurance Click here to enter text. Deductible Click here to enter text,Premium Click here to enter text. Expiration Date Click here to enter a date,Retro Date Click here to enter a date.
kk If the Applicant currently purchases Media Liability Insurance. If Yes please provide,Coverage Description Click here to enter text. Carrier Click here to enter text,Limit of Insurance Click here to enter text. Deductible Click here to enter text,Premium Click here to enter text. Expiration Date Click here to enter a date,Retro Date Click here to enter a date. Optional Additional comments regarding Current Coverage. Click here to enter text,PF 48404 10 16 11,FRAUD WARNING STATEMENTS.
The Applicant s submission of this Application does not obligate the Company to issue or the Applicant to. purchase a policy The Applicant will be advised if the Application for coverage is accepted The Applicant hereby. authorizes the Company to make any inquiry in connection with this Application. Notice to Arkansas Minnesota New Mexico and Ohio Applicants Any person who with intent to defraud or. knowing that he she is facilitating a fraud against an insurer submits an application or files a claim containing a false. fraudulent or deceptive statement is or may be found to be guilty of insurance fraud which is a crime and may be. subject to civil fines and criminal penalties, Notice to Colorado Applicants It is unlawful to knowingly provide false incomplete or misleading facts or. information to an insurance company for the purpose of defrauding or attempting to defraud the company Penalties. may include imprisonment fines denial of insurance and civil damages Any insurance company or agent of an. insurance company who knowingly provides false incomplete or misleading facts or information to a policy holder or. claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a. settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within. the Department of Regulatory agencies, Notice to District of Columbia Applicants WARNING It is a crime to provide false or misleading information to. an insurer for the purpose of defrauding the insurer or any other person Penalties include imprisonment and or fines. In addition an insurer may deny insurance benefits if false information materially related to a claim was provided by. the applicant, Notice to Florida Applicants Any person who knowingly and with intent to injure defraud or deceive any insurer. files a statement of claim or an application containing any false incomplete or misleading information is guilty of a. felony of the third degree, Notice to Kentucky Applicants 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. Notice to Louisiana and Rhode Island Applicants Any person who knowingly presents a false or fraudulent. claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty. of a crime and may be subject to fines and confinement in prison. Notice to Maine Tennessee Virginia and Washington Applicants It is a crime to knowingly provide false. incomplete or misleading information to an insurance company for the purpose of defrauding the company Penalties. may include imprisonment fines or a denial of insurance benefits. Notice to Alabama and Maryland Applicants Any person who knowingly or willfully presents a false or. fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an. application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Notice to New Jersey Applicants Any person who includes any false or misleading information on an application. for an insurance policy is subject to criminal and civil penalties. Notice to Oklahoma Applicants WARNING Any person who knowingly and with intent to injure defraud or. deceive any insurer makes any claim for the proceeds of an insurance policy containing any false incomplete or. misleading information is guilty of a felony, Notice to Oregon and Texas Applicants Any person who makes an intentional misstatement that is material to.
the risk may be found guilty of insurance fraud by a court of law. Notice to Pennsylvania Applicants Any person who knowingly and with intent to defraud any insurance company. or other person files an application for insurance or statement of claim 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 and subjects such person to criminal and civil penalties. PF 48404 10 16 12, Notice to Puerto Rico Applicants Any person who knowingly and with the intention of defrauding presents false. information in an insurance application or presents helps or causes the presentation of a fraudulent claim for the. payment of a loss or any other benefit or presents more than one claim for the same damage or loss shall incur a. felony and upon conviction shall be sanctioned for each violation with the penalty of a fine of not less than five. thousand 5 000 dollars and not more than ten thousand 10 000 dollars or a fixed term of imprisonment for three. 3 years or both penalties Should aggravating circumstances are present the penalty thus established may be. increased to a maximum of five 5 years if extenuating circumstances are present it may be reduced to a minimum of. two 2 years, Notice to New York Applicants Any person who knowingly and with intent to defraud any insurance company or. other person files an application for insurance or statement of claim 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 and shall also be subject to a civil penalty not to exceed five thousand dollars and the. stated value of the claim for each such violation,MATERIAL CHANGE. If there is any material change in the answers to the questions in this Application before the policy inception date the. Applicant must immediately notify the Company in writing and any outstanding quotation may be modified or. DECLARATION AND SIGNATURE, For the purposes of this Application the undersigned authorized agents of the person s and entity ies proposed for. this insurance declare to the best of their knowledge and belief after reasonable inquiry the statements made in this. Application and any attachments or information submitted with this Application are true and complete The. undersigned agree that this Application and its attachments shall be the basis of a contract should a policy providing. the requested coverage be issued and shall be deemed to be attached to and shall form a part of any such policy The. Company will have relied upon this Application its attachments and such other information submitted therewith in. issuing any policy, The information requested in this Application is for underwriting purposes only and does not constitute notice to the.
Company under any policy of a Claim or potential Claim. This Application must be signed by the risk manager or a senior officer of the Parent Organization acting as the. authorized representative of the person s and entity ies proposed for this insurance. Date Signature Title,PF 48404 10 16 13, SIGNATURE FOR ARKANSAS MISSOURI NEW MEXICO NORTH DAKOTA AND. WYOMING APPLICANTS ONLY, PLEASE ACKNOWLEDGE AND SIGN THE FOLLOWING DISCLOSURE TO YOUR APPLICATION FOR. I UNDERSTAND AND ACKNOWLEDGE THAT THE POLICY FOR WHICH I AM APPLYING CONTAINS A. DEFENSE WITHIN LIMITS PROVISION WHICH MEANS THAT CLAIMS EXPENSES WILL REDUCE MY. LIMITS OF LIABILITY AND MAY EXHAUST THEM COMPLETELY SHOULD THAT OCCUR I SHALL BE LIABLE. FOR ANY FURTHER CLAIMS EXPENSES AND DAMAGES, Applicant s Signature Arkansas Missouri New Mexico North Dakota Wyoming Applicants In Addition To. Application Signature Above,Signed must be Officer of Applicant. Print Name Title,Date MM DD YY,Email Phone,SIGNATURE FOR KANSAS AND ALASKA APPLICANTS ONLY.
ELECTRONIC DELIVERY SUPPLEMENT, You are required by law to obtain consent from insureds prior to engaging in any electronic delivery of insurance. policies and or other supporting documents in connection with the policy You have the right to. Select electronic delivery check here,Reject electronic delivery check here. Applicant s Signature Kansas and Alaska Applicants In Addition To Application Signature Above. FOR FLORIDA APPLICANTS ONLY FOR IOWA APPLICANTS ONLY. Agent Name Broker,Agent License ID Number Address,PF 48404 10 16 14.

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