During the past 5 years did you or any partner director, officer, partner, employee, independent contractor or subcontractor place, or over the next 12 months do you or any partner, director, officer, employee, independent contractor or subcontractor expect to place, mutual funds or any other securities? Yes No (If YES, please complete the MGA/MGU, TPA and Mutual Funds Questionnaire) Please provide the following information for business placed by or on behalf of you and sources of other income: Projected 12 Months Current 12 Months Prior 12 Months Total P&C premium volume $ $ $ Total Life and A&H premium volume: $ $ $ Total P&C commission income $ $ $ Total Life and A&H commission income: $ $ $ Other income including sources of the income: $ $ $ Total Commission & Fee Income $ $ $ Please provide the percentage of: policies written on a direct bill basis: % gross written premium placed through a service center: % policies placed with Admitted Carriers: % gross written premium placed through a state administered fund: % business written through MGAs, other brokers or intermediaries: % Please provide the following premium volume for your past 12 months production: COMMERCIAL LINES PERSONAL LINES CMP/Package $ Auto-Standard $ CGL/Package $ Auto-Non-Standard $ Umbrella/Excess $ Homeowners $ Auto-Standard $ Non-Standard Fire $ Auto-Non-Standard $ Pleasure Boats $ Long Haul Trucking $ Mobile Homes/RVs $ Workers Compensation $ Motorcycles $ Livestock Mortality $ Wind/Flood/Earthquake $ Crop/Hail $ Umbrella $ Medical Malpractice $ Other (specify): $ Professional Liability/D&O $ TOTAL PERSONAL LINES $ Wet Marine $ Inland Marine $ LIFE AND A&H INSURANCE Bonds/Surety $ Life, Individual $ Aviation $ Life, Group $ Products liability $ A&H, Individual $ Other (specify): $ A&H, Group $ TOTAL COMMERCIAL LINES $ Annuities $ HMO/PPO/DSP $
First-Party Loss and Business Interruption a) Have any of you experienced or had your system or website used in any of the following types of security incidents or attacks (check all that apply)? security breach denial of service attack transmission of malicious code (ex: virus) identity theft disclosure of private information credit/debit card fraud repudiation of access network outage other security incident extortion threat/demand For each item checked above, please describe the incident or attack, impact to you, customers or others and what measures you have taken to prevent a similar event (attach additional sheets, if necessary) For each security incident or attack indicated above, please provide the following (attach additional sheets, if necessary): Type of Security Incident or Attack: Type of Security Incident or Attack: Duration of each outage Total net income loss due to the outage $ $ Total number of records affected in each security incident or attack Total cost for forensic examination to determine origin, extent and duration of each security incident or attack $ $ Total cost for notification to persons affected by the security incident or attack $ $ for call center costs associated with notice $ $ and for credit monitoring offered to affected persons $ $ Total legal costs associated with the security incident or attack $ $ Total amount of PCI fines and government fines $ PCI Fines $ Government Fines $ PCI Fines $ Government Fines Total costs for customer redress (other than referenced above) $ $