DHS10008 - Application for Safety Act Designation

OMB No. 1640-0001
Expires: 10/31/06
DEPARTMENT OF HOMELAND SECURITY

Application for SAFETY Act Designation

APPLICATION TYPE
D1. Type of Application. This application is a(n) (choose one):
Initial Filing
Application following a Pre-Application Consultation
Application ID #:
Resubmission of a Previous Application
Application ID #:
Application for Renewal of Designation
Application ID #:
EXPEDITED REVIEW
D2. Request for Expedited Review
In its discretion, the Department may identify categories of anti-terrorism
Technologies for which expedited processing may be granted. For example, the
Under Secretary may conduct expedited processing for applications that are the
subject of a pending Federal, State or local procurement, that addresses a particular
threat, that involve particular types of anti-terrorism Technologies or for other
reasons. If you are requesting expedited review, please specify the basis for such
request, including, if applicable, information concerning an ongoing procurement.
Such information should include the following.
a. The name of procuring organization;
b. Contact information for relevant government procurement official;
c. The related Request for Proposal (RFP) number or other official identifierof
the procurement, if available; and
d. Upcoming deadlines relating to the procurement (e.g., submission deadline,
decision/contract award, etc.)
Please note if your application falls under a published DHS Notice of Expedited
Processing and provide the referance number for such Notice a brief statement as to
why your application falls within the scope of the Notice. If you wish to provide
other bases for expedited processing please specify.
D3. REGISTRATION INFORMATION
Registration Status (choose one):
My initial Seller registration is included with this application.
I am updating or correcting previous registration information.
DHS Form 10008 (10/06)

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My previously provided registration information is still accurate.
D3.1

Seller Name:

OVERVIEW OF THE ANTI-TERRORISM TECHNOLOGY
D4. Non-proprietary Summary
D4.1 Name of your Technology:
D4.2 Company and Technology Description. Provide an overview of your company,
including the place of incorporation a description of your business, and the
Technology that is the subject of this Application.

D5. Nature of your Technology. If your Technology is a product or device, please
describe the Technology in detail, including its principal elements, system and
components. If your Technology is a service, please describe the nature of the
service, the actions, activities, planning, training, and/or expertise involved in
providing the service and how the service is designed to counter terrorist threats. If
your Technology is an "integrator" of various products, services, or legacy systems
indicate how the Technology will integrate the various component parts.

D6 . Past sales and ongoing procurements. Note: It may be vary important and could
significantly expidite your application if your Technology has been acquired or
utilized (or is subject to an ongoing procurement) by the military, a Federal
government agancy, or a state, local or foreign government entity.
D6.1. Who has purchased or plans to purchase your Technology? (choose all that apply.)
Please provide a brief description of such purchases.
Federal governement (Agency:

Approximate Date:

)

State governement (State:

Approximate Date:

)

Local governement (City/County:

Approximate Date:

)

Commercial organization (Name:

Approximate Date:

)

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Foreign government (Name:

Approximate Date:

)

D6.2 Contact Information. Include name, address, phone number, and e-mail address or
procuring officials, if available.
D6.3 If applicable, provide information regarding your Technology's use by the United
States Government or by any state, local, or foreign government.
D6.4 Please identify any determination made by Federal, State, or Local government
officials in any past or ongoing procurement or other context that your Technology
is appropriate for the purpose of countering terrorism.
D7. If any other corporate intity or entities should be identified as an authorized Seller of
the subject Technology in addition to the firm identified in the response to D3.1
above, please identify each entity and the place in which it is organized.
D8. Provide the earliest date of sale of the Technology for which you are requesting
SAFETY Act coverage.
DESIGNATION AS A QUALIFIED ANTI-TERRORISM TECHNOLOGY
Respond to all items in this section in one attachment to this application. Additional
supporting material may be attached as an appendix to your application.
D9. Description of your Technology. Describe your Technology in detail. This
description will serve as the basis for the Department's analysis of your Technology
for SAFETY Act purposes. The content of the response you provide in the section,
together with any additional information you may be asked to provide, may be used
to finalize of the definition and scope of your Technology as it will appear in a
Designation.
D10. Deployment and Operation. Describe the sequence of steps involved in deploying
and operating your Technology.
D11. Readiness for Sale. How ready is your Technology to be sold and deployed?
D12. Magnitude of Risk. Please provide an assessment of the magnitude of risk to the
public from the type of terrorist activities your Technology would counter. Please
describe, to the extent practicable, the scope of the injury, property damage,
economic loss, damage, loss of life, or other harm that could result from such
terrorist activity. Please describe how the Technology has been deployed to date and
how it can counter terrorist activities.
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D13. Please describe how your plans for selling, deploying, or maintaining your Technology
would be affected if the Department does not issue SAFETY Act Designation for your
Technology. Please describe how the Technology will be deployed in the future if
SAFETY Act Designation is issued.
D14. Effectiveness and Utility. Provide information supporting the potential for your
Technology to be effective in countering potential acts of terrorism. Please provide
internal or external effectiveness tests or other information indicating the effectiveness of
your Technology. This can include acceptance test data from a government contracting
action, customer feedback or other relevant data or experience. As noted, acceptance of
your Technology by a government purchaser may be highly relevant and expedite
approval or your application.
D15. Include any other information the Department should consider in evaluating your
anti-terrorism technology.
D16. Insurance Data

D16.1

Please provide the information indicated below for any and all current liability
insurance policies that are available to satisfy otherwise compensable third-party
claims arising out of, relating to, or resulting from an act of terrorism were your
Technology deployed in defense against or response to or recovery from such
act:
a. Primary named insured (as it appears on your insurance policy).
b. Additional named insured relevant to the Technology Sellers.
c. Type of policiy(ies) (e.g. Comprehensive General Liability, Errors and
Omissions,Aviation, Product Liability, SAFETY Act Liability, etc.)
d. Policy Dates. (Start and End)
e. Insurer.
f. Per occurrence limits. 1
g. Aggregate limits.
h. Annual Premium(s). 2
i. Deductable(s) or Self-insured retentions.
j. Exclusions (please note and explain any pertinent insurance exclusions,
cancellation terms or limits that would potenttially dilute or eliminate
the availability of coverage under the policies identified in subparagraph
"c"above.)
k. Please describe the type and limits of terrorism coverage for this policy.
Pleaseelaborate on the applicability of the policies identified in subparagraph
"c" to address the foreseeable risk associated with the deployment of the
Technology including those risks arising from the deployment of the
Technology in advance of or responce to an act of terrorism.

1 Please indicate whether the policy(ies) has a different limit or deductable/selfinsuredretention for terrorist acts then the general policy limit and, if so, provide both.
2 Insurance premium: If possible, please indicate what percentage of the premium is allotted to
coverage for Acts of Terrorism.
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Please also indicate whether the identified policy(ies) provides coverage under the Terrorism
Risk Insurance Act (TRIA) of 2002, as amended, or other insurance policy(ies)provisions of
endorsements.
l. Please describe whether the relevant policy(ies) cover SAFETY Act claims and Whether
the policy(ies) has a dedicated limit that applies to SAFETY Act claims only or has a
shared limit (i.e, shared with non-SAFETY Act claims). Please indicate whether you have
received a written interpretation letter from either the carrier or insurance broker indicating
whether the policy covers SAFETY Act claims; if so, please provide a copy of such
document.
D16.2 Unavailability of Insurance.
a. If you do not currently carry insurance for the Technology that would be applicable in the
event of an Act of Terrorism, please indicate the reasons. If you have attempted to
purchase insurance but it is not available on the world market, please so indicate with
specificity the inquiries you have made. (you may submit written communications from
insurance companies or brokers explaining why your Technology cannot be insured.
b. If you have endeavored to purchase insurance but have not done so because you have
concluded that the cost of insurance premiums would unreasonably distort the price of the
Technology, please describe those efforts to find appropriate insurance and state why you
have concluded that the cost of insurance for your Technology would unreasonably distort
it sales price, In this context, you may need to provide an explanation with relevant
documentation (e.g., insurance quotes with limits, premiums, elusions and other key items
plus other relevant financial and market data). Note: The Department recognizes that the
discussion of requisite insurance with an Applicant may require a number of
communications during the pendency of an application. Thus, the question of whether a
given premium would "distort the sales price" of a Technology might not arise when
the Application is submitted. If the question does arise later in the process, the
application may submit appropriate information at that time.
D16.3 Insurance point of Contact Provide a point of contact, including telephone number and
email address for someone authorized to discuss your company's insurance information
with the Department. This point of contact may be the same person identified in your
registration statement and may be your counsel, insurance expert, or any other
personwith appropriate information.
D17. Financial Data
Certain financial information regarding your company and projected/prospective Technology
revenue is particularly relevant to the application process. This is particularly true when
questions arise as to whether insurance costs for specified coverage limits unduly distort the
price
of your Technology. We may request additional financial information from the Applicant if
necessary during the Application process.
D17.1 You may provide a copy of the Seller's financial statement for the most recent fiscal year.
For public companies, the most recent SEC annual report (Form 10-k) and SEC quarterly
report (Form 10-Q) together with any amendments thereto, should suffice. For nonpublically traded companies, you may choose to include the following information for the
most recent fiscal year: income statement, state of cash flow and balance sheet as well as

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pro forma financial statement. OSAI will seek additional and more specific
information only when necessary for a particular application.

ADDITIONAL ATTACHMENTS
Provide additional supporting documentation

DECLARATION FOR WRITTEN SUBMISSIONS
I declare, to the best of my knowledge and belief, that the information provided in response to the
questions set forth in this Application for SAFETY Act liability protections is true, factual, and correct,
and that I am an authorized agent of the Applicant.
Prepared By:

Title (if applicable):

Signature:

Date:

/

/20

The signature of the Preparer must be notarized below:
State of:
Subscribed and sworn before me this

County of:

day of

Notary Public:
My Commission Expires on:

Privacy Act Notice: DHS will use the information on Form OMB 1640-0001 to determine eligibility for
the requested SAFETY Act protections. This information is to be regarded as “SAFETY Act
Confidential” and protected from release pursuant to §25.10 of the Regulations Implementing the
SAFETY Act of 2002, 6 C.F.R., Part 25, 71 Fed. Reg. 33147, 33159 (June 6, 2006).
Burden Statement: Public reporting burden for this form is estimated at 3.5 hours per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and checking the collection forms. This effort is necessary to obtain or
retain a benefit, as required by Public Law 107-296, Subtitle G of Title VIII of the Homeland Security
Act of 2002. Written comments regarding this form should be submitted to the Office of SAFETY Act
Implementation, Department of Homeland Security, Science and Technology Directorate. Comments
should be addressed and mailed to Silvia Cabrera, Acting Director OSAI, Department of Homeland
Security/ Science and Technology Directorate, Washington, D.C. 20528, or sent via electronic mail to
[email protected], or faxed to (703) 575-8416.

DHS Form 10008 (10/06)

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