148 Electronic Data Processing Section
Applicant (first named insured)
*
Effective date
*
Expiration date
*
Premises Information
Location number
Building number
Subject of insurance: Equipment (hardware)-owned
Limit of insurance ($)
Valuation type
Select
ACV
RC
Other
Percent coinsurance
Deductible ($)
Subject of insurance: Equipment (hardware)-leased
Limit of insurance ($)
Valuation type
Select
ACV
RC
Percent coinsurance
Deductible ($)
Subject of insurance: Equipment (hardware)-in transit
Limit of insurance ($)
Valuation type
Select
ACV
RC
Percent coinsurance
Deductible ($)
Subject of insurance: Media/Data software
Limit of insurance ($)
Valuation type
Select
Reproduction
Percent coinsurance
Deductible ($)
Subject of insurance: Media/Data software in transit
Limit of insurance ($)
Valuation type
Select
Reproduction
Percent coinsurance
Deductible ($)
Subject of insurance: Extra expense (if applicable)
Limit of insurance ($)
Valuation type: Period of restoration
Percent coinsurance
Deductible ($)
Subject of insurance: Business interruption (if applicable)
Limit of insurance ($)
Valuation type: Per day limit
Valuation type: number of days
Percent coinsurance
Deductible ($)
Deductible waiting period (hours)
Subject of insurance: Mechanical breakdown
Select
Yes
No
Limit of insurance ($)
Deductible ($)
Subject of insurance: Protection and control system
Limit of insurance ($)
Valuation type
Percent coinsurance
Deductible ($)
Subject of insurance: Other
Limit of insurance ($)
Valuation type
Percent coinsurance
Deductible ($)
Subject of insurance: Flood coverage
Select
Yes
No
Zone
Location of equipment
Select
Above ground
Below ground
Ground level
Subject of insurance: Earthquake coverage
Select
Yes
No
Building construction type
Protection class
Number of stories
Year built
Schedule of equipment
Location 1
Building number
Item number
Manufacturer
Model
Serial number
Leased or owned?
Select
Leased
Owned
Current full 100% value
Amount of insurance (coinsurance percentage)
Location 2
Building number
Item number
Manufacturer
Model
Serial number
Leased or owned?
Select
Leased
Owned
Current full 100% value
Amount of insurance (coinsurance percentage)
Location 3
Building number
Item number
Manufacturer
Model
Serial number
Leased or owned?
Select
Leased
Owned
Current full 100% value
Amount of insurance (coinsurance percentage)
Location 4
Building number
Item number
Manufacturer
Model
Serial number
Leased or owned?
Select
Leased
Owned
Current full 100% value
Amount of insurance (coinsurance percentage)
Location 5
Building number
Item number
Manufacturer
Model
Serial number
Leased or owned?
Select
Leased
Owned
Current full 100% value
Amount of insurance (coinsurance percentage)
Location 6
Building number
Item number
Manufacturer
Model
Serial number
Leased or owned?
Select
Leased
Owned
Current full 100% value
Amount of insurance (coinsurance percentage)
Totals
Total current 100% value
Total amount of insurance (coinsurance percent)
General Information
Explain all YES responses
In the event of a major or total loss could you return to operation within one week?
*
Select
Yes
No
Explain
Do you have an arrangement for the use of other equipment?
*
Select
Yes
No
Explain
Is your equipment manufacturer in a position to replace your equipment promptly?
*
Select
Yes
No
Explain
Explain
Do you have a service maintenance contract with a manufacturerr or other service contractor?
*
Select
Yes
No
Explain
Is the equipment shipped by common carrier?
*
Select
Yes
No
Explain
Is the equipment shipped by company vehicle?
*
Select
Yes
No
Explain
Is the media/data shipped by common carrier?
*
Select
Yes
No
Explain
Is the media/data shipped by company vehicle
*
Select
Yes
No
Explain
Does the premises have a burglar alarm?
*
Select
Yes
No
Explain
Does the applicant have any uninterruptible power source to protect the hardware from power line problems?
*
Select
Yes
No
Explain
Does the applicant have a line conditioner to protect the hardware from power line problems?
*
Select
Yes
No
Explain
Does the applicant have a power suppressor voltage regulator to protect the hardware from power line problems?
*
Select
Yes
No
Explain
Does the applicant have a dedicated line to protect the hardware from power line problems?
*
Select
Yes
No
Explain
Computer Room Information
Explain all YES responses
Is the data processing equipment located in a specifically designated room?
*
Select
Yes
No
Explain
Is access to the equipment controlled by a master shutdown switch?
*
Select
Yes
No
Explain
Is there a separate air conditioning system designed to specifically protect the EDP equipment?
*
Select
Yes
No
Explain
The computer room is protected by the following systems
*
Select
None
Wet Sprinkler
Dry Sprinkler
Halon
CO2
Other
Does the computer room have a raised pedestal floor?
*
Select
Yes
No
Explain
Floor construction type
Select
Combustible
Non-combustible
Below floor protection
Select
Smoke detectors
Halon system or CO system
Other
None
Alarm type temperature
Select
Local
Central
Alarm type humidity
Select
Local
Central
Alarm type smoke
Select
Local
Central
Alarm type fire
Select
Local
Central
Media and Data (software) Information
Explain all YES responses
Are anti-viral safeguards in effect?
Select
Yes
No
Explain
Are duplicates of software maintained?
Select
Yes
No
Explain
How often is data backed up?
Select
Daily
Weekly
Monthly
Quarterly
Yearly
Other
Duplicate software
Select
On premises
Off premises
Data backups
Select
On premises
Off premises
On premises location information
Select
Safe
Vault
Computer room
Other
Off premises storage location information
Name
Address
City
State
Zip
Additional Interests
Additional interest 1
Interest
Select
Additional insured
Loss payee
Mortgagee
Lienholder
Other
Other
Certificate required?
Select
Yes
No
Name
Address
City
State
Zip
Reference number
Interest in item: location number
Interest in item: building number
Interest in item: item number
Interest in item: other
Additional interest 2
Interest
Select
Additional insured
Loss payee
Mortgagee
Lienholder
Other
Other
Certificate required?
Select
Yes
No
Name
Address
City
State
Zip
Reference number
Interest in item: location number
Interest in item: building number
Interest in item: item number
Interest in item: other
53 Loveton Circle, Suite 120 • Sparks, MD 21152
Phone • 1.800.926.8085 • 410.472.1620 • Fax • 410.472.1897
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