DHS Form 10006 (10 Application for SAFETY Act Developmental Testing and Eva

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

Application for SAFETY Act Developmental Testing and Evaluation
Designation

APPLICATION TYPE
TE1. 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 #:
REGISTRATION INFORMATION
TE2. 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:
TE2.1 Seller Name:
TE3. Non-proprietary Summary
TE3.1. Name of your Technology:
TE3.2. 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.
TE4. 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 and the the service is designed to counter terrorist threats.

DHS Form 10006 (10/06)

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DEVELOPMENTAL TESTING AND EVALUATION DESIGNATION
Respond to all items in the section in one attachment to this application. Additional
supporting material may be attached as an appendix to your application.
TE5. Description Specification 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 this 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
Developmental Testing and Evaluation Designation.

TE6. Nature of Test scenario. Please provide an outline of the test plan for the subject
Technology. The outline may include the nature of the test, the entity that will conduct
the test, relevant time frames, proposed test methodology, location of the test, summary
rationale for conducting the test, and any other information that you wish to provide.
TE7. Development and Operation. Describe the sequence of steps involved in deploying and
operating your Technology.
TE8. Magnitude of Risk. Please provide and assessment of the magnatude of risk 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 activities. Please describe
how the Technology has been deployed to date and how it can counter terrorist
activities. If the Technology has not yet been deployed , summarize the prototype
testing or other testing that has been conducted to date.
TE9. Please describe how your plans for selling, deploying, or maintaining your Technology
would be affected if the Department does not issue Developmental Testing and
Evaluation (DT&E) Designation. Please describe how the Technology will be deployed
in the future if SAFETY Act DT&E Designation is issued.
TE10. Effectiveness and Utility. Provide information supporting the potential for your
Technology to be effective in countering potential act of terrorism.
TE11. Summarize your Technology's qualifications for SAFETY Act Developmental Testing
and Evaluation Designation. Include any other information the Department should
consider in
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evaluating your anti-terrorism technology. Please include information relating to interest by
governmental entities in testing or provisionally deploying your Technology.
TE12. Insurance Data

TE12.1 Please provide the information below for and and all current liability insurance policies
that you hold and 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 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.) and any
relevant endorsements.
d. Policy Dates. (Start and End)
e. Insurer.
f. Per occurrence limits.4
g. Aggregate limits.
5
h. Annual Premium(s).
i. Deductable(s) or Self-insured retentions.
j. Exclusions (please note and explain any pertinent exclusions or cancellation
terms that would potenttially dilute or eliminate the availability of coverage of
any of the policies identified in subparagraph "c" above.)
k. Does your insurance policy(ies) cover the type of developmental test and
evaluation and ctivities anticipated in this application? If yes, please describe.
l. Please describe the type and limits of terrorism coverage for this policy. Please
elaborate on the applicability of the policies indentified in subparagraph "c" to
address the foreseeable risk associated with the deployment of the Technology
including those risk arising from 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.
m. 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., 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.
4 Please indicate whether the policy(ies) has a different limit or deductable/self-insured retention for
terrorist acts then the general policy limit and, if so, provide both.
5 Insurance premium: If possible, please indicate what percentage of the premium is allotted to coverage
for Acts of Terrorism.
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n. Is your Technology indemnified by a third party organization or entity (including
the U.S. Government) for the test and evaluation described in this application.? If
so, please describe the key terms and conditions and limits of indemnification.
TE12.2 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 reason. 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 quoted 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.
D12.3

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 you registration statement and may
be your counsel, insurance expert, or any other person with appropriate information.

TE13. 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 information from the Applicant if
necessary during the Application process.
D13.1 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 non-publically 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 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 10006 (10/06)

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