Cyber Liability - Charter Safe

Cyber/Privacy/Network Security Liability Insurance Program

CharterSAFE members now have the opportunity to take advantage of group pricing on a custom insurance program designed to mitigate the risks associated with data breach and communications in today’s electronic environment.

Please fill out the brief form below to determine eligibility for the program. IMPORTANT - applications must be completed and verified in order for your school or organization to be added as an Additional Insured to the policy.

Applicant Name:

Your Name:

Address:

City:

State:

Zip:

Website:

Phone:

Student Enrollment:

CONTACT US

Jennifer Rubin, Managing Director, Schools Insurance
(888) 901-0004 ex. 10
jrubin@chartersafe.org

Are you or anyone in your organization aware of any fact, circumstance or situation that could give rise to a claim under this or similar insurance policy?

Yes

If yes, have you reported same to your current insurer?

Yes

N/A

If yes, please provide an explanation of each and current status in the space provided below:

THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. UNDERWRITER ACCEPTANCE OF THE APPLICATION IS REQUIRED PRIOR TO BINDING COVERAGE. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION AND MADE A PART HEREOF.

By checking “Yes” below, the Applicant certifies that he or she is an authorized representative of the applicant identified in “APPLICANT NAME” and certifies that reasonable inquiry has been made to obtain the answers to these questions. He or she certifies that the answers are true, correct and complete to the best of his/her knowledge.

Yes

Applicant Title:

Applicant Email: