DHS Form 10005 (10 SAFETY ACT BLOCK DESIGNATION APPLICATION

OMB No. 1640-0001
Expires: 10/31/06

DEPARTMENT OF HOMELAND SECURITY

SAFETY ACT BLOCK DESIGNATION APPLICATION
APPLICATION TYPE
BD1. Type of Application.
I am responding to an announced Block Designation. Reference:
Date issued:
; Technology name:
Resubmission of a Previous Application for an announced Block Designation.
Reference:
Previous Application ID#:
Date issued:
; Technology name:

REGISTRATION INFORMATION
BD2. Registration Status (choose one):
My initial registration is included with this application.
I am updating or correcting previous registration information.
My previously provided registration information is still accurate.

BD3. Name of Seller:
BD4. Company 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.

BLOCK DESIGNATION
Respond to all items in this section in an attachment to this application. Additional
supporting material can be attached as an appendix to your application.

BD5. If any other corporate entity or entities should be identified as an authorized Seller of the
subject Technology in addition to the firm identified in the response to BD3.1 above, please
identify each entity and the place in which it is organized.

BD6. Provide the earliest date of sale of the Technology for which you are requesting SAFETY Act
coverage.

BD7. Identify the Block Designation you are responding to by noting the name of the Block
Designation and the date it was issued. Reference any special terms or conditions presented
in the referenced Block Designation.

BD8. Submit information demonstrating your Technology's conformance with the technical
specifications or standards of the Block Designation.

DHS Form 10005 (10/06)

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BD9. Submit information demonstrating your Technology's compliance with the terms and
conditions of the referenced Block Designation.

BD.10 Submit any other information concerning the Technology which may be helpful to the
Department in considering this application.

BD.11 Insurance Data.
BD.11.1 Please provide the information 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 where your Technology deployed in
defense against or in response 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 policy(ies) (e.g., Comprehensive General Liability, Errors and Omissions,
Aviation, Product Liability, SAFETY Act Liability, etc.) and any relevant endorsements.
d. Policy Dates. (Start and end)
e. Insurer.
f. Per occurrence limits.6
g. Aggregate limits.
h. Annual Premium(s).7
i. Deductible(s) or Self-insured retentions.
j. Exclusions (please note and explain any pertinent insurance exclusions or cancellation provisions
that would potentially dilute or eliminate the availability of coverage of any of the policies identified
in subparagraph "c" above).

k. Please describe the type and limits of terrorism coverage for this policy. Please elaborate
on the applicability of the policies identified in subparagraph "c" to address the foreseeable
risks associated with the development of the Technology including those risks arising from
the deployment of the Technology in advance of or response to an act of terrorism. 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 or
endorsements.
l. Please also 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

6

Please indicate whether the policy(ies) has a different limit or deductible/self-insured retention for
terrorist acts than the general policy limit and, if so, provide both.
7
Insurance premium: If possible, please indicate what percentage of the premium is allotted to coverage
for Acts of Terrorism.
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indicating whether the policy covers SAFETY Act claims; if so, please provide a copy of
such document.

BD.11.2 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
its sales price. In this context, you may need to provide an explanation with relevant
documentation (e.g., insurance quotes with limits, premiums, exclusions 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
Applicant may submit appropriate information at that time.

BD.11.3 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 of any other person with
appropriate information.

BD12. Financial Data.
Certain financial information regarding your company and projected/prospective Technology
revenue may be 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.

BD.12.1 Please 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 nonpublicly 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 pro forma financial
statement. OSAI will seek additional and more specific information only when necessary
for a particular application.

ADDITIONAL ATTACHMENTS
Provide all supporting documentation.

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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 6 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 10005 (10/06)

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