SAFETY Act Application Kit
July 2006
U.S. Department of Homeland Security
Science and Technology Directorate
245 Murray Lane, Building 410
Washington, D.C. 20528
1-866-788-9318
http://www.safetyact.gov
We are pleased to release the July 2006 version of the U.S. Department of Homeland Security SAFETY Act Application Kit. This Application Kit provides you with all of the necessary guidelines for applying for the liability protections available under the SAFETY Act and taking certain follow-on actions. It simplifies previous versions of this kit to reduce burdens and to refine questions to reflect recent regulatory changes.
If you seek SAFETY Act coverage, you must formally apply using the forms provided by the Department in this Application Kit. You will be asked to furnish supporting data and information to demonstrate your technology’s effectiveness. The Department will review your application to determine the technology’s eligibility for SAFETY Act Designation.
We have incorporated many helpful suggestions from the public in this new version of the SAFETY Act Application Kit in order to make the SAFETY Act application process more efficient and user-friendly. Although this version has changed to reflect comments and experience with the program, the Department will continue to take and review comments and will make further changes as appropriate in the coming months. We encourage and welcome feedback that will further improve our procedures and enhance our ability to conduct timely and thorough evaluations of applications. For additional information on the application process and statute, please visit the SAFETY Act Web site (http://www.safetyact.gov). Please direct any questions or comments associated with the SAFETY Act or these instructions to the SAFETY Act Information Desk:
Phone:
1-866-788-9318
E-mail: helpdesk@safetyact.gov
Linda Vasta
Acting Director
Office of SAFETY Act Implementation
Science and Technology Directorate
U.S. Department of Homeland Security
Number: 1640-0001
Expiration: xxxx xx, 200x
Public reporting burden for this collection of information is estimated at 60 – 180 hours per response (average = 120 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.
The SAFETY Act provides incentives for the development and deployment of Qualified Anti-Terrorism Technologies by creating a system of “risk management” and a system of “litigation management.” The purpose of the Act is to ensure that the threat of liability does not deter potential manufacturers or Sellers of Qualified Anti-Terrorism Technologies from developing and commercializing technologies that could significantly reduce the risks or mitigate the effects of large-scale terrorist events.
Send questions regarding any aspect of this collection of information to:
Science and Technology
Directorate
c/o Office of SAFETY Act Implementation
U.S.
Department of Homeland Security
245 Murray Lane, Building 410
Washington, D.C. 20528
and to:
Office of Management and
Budget
Paperwork Reduction Project (1640-0001)
Washington,
D.C. 20503
P
Chapter 1. About the SAFETY Act Application Kit 711
Chapter 2. Registration as a seller of anti-terrorism technology 715
Chapter 3. Request for A Pre-Application Consultation 719
Chapter 4. Application for SAFETY Act Designation 725
Chapter 5. Application for safety act certification 744
Chapter 6. Application for SAFEty Act Developmental testing and evaluation designation 752
Chapter 7. SAFEty Act Block Designation Application 767
Chapter 8. SAFEty Act Block certification Application 776
Chapter 9. Notice of license of qualified anti-terrorism technology 782
Chapter 10. Notice OF MODIFICATION of Qualified Anti-Terrorism Technology 787
chapter 11. Application for Transfer of SAFETY ACT Designation 791
The SAFETY Act Application Kit provides instructions and the requisite forms to file with the Department of Homeland Security (DHS) in order to take the following actions:
Register with the Office of SAFETY Act Implementation (OSAI): The first step to apply for SAFETY Act Designation of your Technology as a Qualified Anti-Terrorism Technology or to request a Pre-Application Consultation is to register with OSAI as a potential Seller. This establishes an official point of contact for the Department to use in its interactions with you concerning your Technology and to create a unique identification number for you. Registering with the OSAI will also provide you with access to OSAI’s online application program.
Request a Pre-Application Consultation: You may obtain guidance from OSAI prior to submitting a full application for Designation via a Pre-Application Consultation. Use this form to request a Pre-Application Consultation with OSAI. OSAI recommends a Pre-Application Consultation for each applicant, seeking preliminary guidance as to whether their Technology may be Designated as a Qualified Anti-Terrorism Technology.
Apply for Designation as a Qualified Anti-Terrorism Technology (QATT).
Apply for Certification as an Approved Product for Homeland Security.
Apply for Developmental Testing and Evaluation (DT&E) Designation.
Apply pursuant to a Block Designation.
Apply pursuant to a Block Certification.
Submit a Notice of License of a SAFETY Act Designation or Certification.
Submit a Notice of Modification of a SAFETY Act Designation or Certification.
Apply for a Transfer of a SAFETY Act Designation or Certification.
While many firms may apply for Designation of their Technology as a Qualified Anti-Terrorism Technology in the first instance and, either concurrently or subsequently, Certification of their QATT as an Approved Product for Homeland Security, the SAFETY Act final rule provides additional options for those seeking liability protections available under the SAFETY Act. The Department, through the SAFETY Act final rule, has provided for “Developmental Testing and Evaluation Designations” as well as “Block Designations” and “Block Certifications,” which provide for added flexibility in taking actions in furtherance of the SAFETY Act’s objective.
The incorporation of Developmental Testing and Evaluation (DT&E) Designations recognizes that there may be instances of certain anti-terrorism technologies being developed that could serve as an important homeland security resource but that require additional developmental testing and evaluation, e.g., a prototype of a particular technology that has undergone successful lab testing may require field testing or a controlled operational deployment to validate its safety and efficacy. A DT&E Designation makes available the system of litigation and risk management established by the SAFETY Act albeit with certain limitations and conditions that otherwise would not attach to Qualified Anti-Terrorism Technologies. DT&E Designations will facilitate the deployment of promising anti-terrorism technologies in the field either for test and evaluation purposes or in response to exigent circumstances by providing, on a limited basis, the liability protections offered by the SAFETY Act.
Applicants seeking SAFETY Act protections for promising anti-terrorism technologies that have not yet been deployed in an operational environment or that require additional testing and evaluation should consider applying for DT&E Designation. In general, DT&E Designations will include limitations on the use and deployment of the subject technology, remain terminable at-will by the Department should any concerns regarding the safety of technology come to light, and have a limited term not to exceed a reasonable period for testing or evaluating the technology (presumptively not longer than 36 months). Further, the SAFETY Act liability protections associated with DT&E Designations will apply only to acts that occur during the period set forth in the particular DT&E Designation. DT&E Designations are intended to provide the Department with flexibility in making available the SAFETY Act’s system of risk and litigation management, and the Department may issue a DT&E Designation for anti-terrorism technologies that show promise but that may not yet meet the requirements for Designation as a QATT. Technologies that receive DT&E Designation may subsequently qualify for Designation as a Qualified Anti-Terrorism Technology.
The Department also has established streamlined procedures for providing SAFETY Act coverage for qualified Sellers of certain categories of Technologies through the use of “Block Designations” or “Block Certifications.” Block Designations and Block Certifications are issued at the Under Secretary’s discretion and are intended to recognize anti-terrorism technologies that meet the technical criteria for Designation as a Qualified Anti-Terrorism Technology and are based on established performance standards or defined technical characteristics. Fundamentally, the Department’s issuance of a Block Designation or Block Certification announces to potential Sellers of the underlying QATT that the Department has determined that the QATT satisfies the technical criteria for either Designation or Certification and that no additional technical analysis will be required in evaluating SAFETY Act applications from potential Sellers of that QATT. The terms of any such Block Designation or Block Certification will establish the procedures and conditions upon which an applicant may receive SAFETY Act coverage as a Seller of the subject technology. Applications from potential Sellers of a QATT that is the subject of a Block Designation or Block Certification will receive expedited review and will not require submission of information concerning the technical merits of the underlying technology. All Block Designations and Block Certifications will be published by the Department within ten days after the issuance thereof at http://www.safetyact.gov, and copies may also be obtained by mail by sending a request to: Directorate of Science and Technology, Office of SAFETY Act Implementation, Room 4320, Department of Homeland Security, Washington, DC 20528. Any person, firm, or other entity that desires to qualify as a Seller of a QATT that is the subject of a Block Designation or Block Certification should utilize the forms provided in this Application Kit and follow the instructions set forth herein as well as included in the specific Block Designation or Block Certification issued by the Department.
This Application Kit contains the forms necessary to communicate with OSAI about your Technology.
Certain defined terms are used throughout this Application Kit. These terms and their meanings are set forth below.
Sell (sale, sales, selling): In this Application Kit, “Sell” is used as a generic term for the means by which you make your QATT available to the market as a whole or to a particular customer, e.g., government agency. “Selling” should be understood to include not only providing tangible goods or services for value received, but also executing contracts for services to be rendered, leasing, exchanging, donating, contingency-fee services, or any other transaction or arrangement by which your QATT is made available. The term “customer” is used in the same broad way to mean the recipient or user of your QATT. In this context, a single entity may be both the “Seller” and the customer in the event such entity is deploying its QATT internally.
Technology: In this Application Kit, “Technology” is defined as “any product, equipment, service (including support services), device, or technology (including information technology)” and may include a combination of products, equipment, expertise, and services.
Counter: Technologies can perform many different functions in the fight against terrorism. These functions may include, for example, predicting where terrorist acts are most likely to occur, deterring acts of terrorism, assessing vulnerability to terrorist threats, allocating resources among counter terrorism activities, responding to acts of terrorism, detecting preparations for terrorist activities, detecting terrorist acts in progress or disrupting them, hardening targets against terrorist attacks, improving first responder performance in the event of a terrorist act, mitigating the effects of a terrorist attack, improving medical treatment of terrorism victims, and many others. All of these roles, whether in anticipation of potential terrorist acts or in response to actual terrorist acts, will be referred to in this application Kit as countering acts of terrorism.
Assistance
The Office of SAFETY Act Implementation (OSAI) will answer any questions or provide additional information through the application process. Please direct all requests or questions to: OSAI at 1-866-788-9318 or helpdesk@safetyact.gov.
The initial step in applying for the liability protections available under the SAFETY Act or for requesting a Pre-Application Consultation is to register with OSAI. Registration can be done electronically at the SAFETY Act Web site (http://www.safetyact.gov). You can also register by mail, using the forms included in this kit, or you can download an electronic copy of the form, complete it, and mail in the electronic document on a compact disc. Mailed registrations (hard copy or CD) should be sent to:
U.S. Department of Homeland
Security
ATTN: Office of SAFETY Act Implementation
245
Murray Lane, Building 410
Washington, D.C. 20528
Remember that physical mail sent to DHS is screened and processed, which may delay the Department’s response to your submission.
Registering with OSAI does not commit you to any further actions. The purpose of Registration is to establish an official point of contact for the Department to use in its interactions with you concerning your Technology and to create a unique identification number for you as a potential Seller. This identifier will help the Department track and maintain your application. The SAFETY Act application process is designed to be flexible and to involve ongoing dialogue with the Applicant. Appropriate “points of contact” will facilitate this dialogue. The Applicant’s point of contact may be any person you desire to coordinate your application and may include counsel, a representative of management, a technical expert or any other person you consider appropriate for this purpose.
(Registration Form on following page)
Registration as a Seller of Anti-Terrorism Technology
Action
R1. Purpose of Registration (choose one):
Initial Registration
Updated or Corrected Registration Information
Registration Data
R2. Seller Name:
R3. Data Universal Numbering System (DUNS) Number (if available): ________________________
R4. North American Industry Classification System (NAICS) Code (if available):
Point-of-Contact Information
R5. Primary Point of Contact:
Name: ____________________________________________________________________
Address:
State/Province: Country: ZIP/Mail Code:
Telephone No.: Fax No.: E-mail:
E-mail Communication Authorized? Yes No
R6. Secondary Point of Contact (optional):
Name: ____________________________________________________________________
Address:
State/Province: Country: ZIP/Mail Code:
Telephone No.: Fax No.: E-mail:
E-mail Communication Authorized? Yes No
Action
If your company or business unit has not previously registered with OSAI, check “Initial registration.” A company may file more than one registration; certain companies may wish to file multiple registrations if it has multiple business units selling dissimilar types of Technologies. As a rule, the entity that sells the Technology is the entity that should register.
If you are updating or correcting previous registration information, check “Updated or Corrected Registration Information.” OSAI strongly encourages you to keep your registration information up to date. In particular, be sure to notify OSAI of any changes in contact information.
Enter the legal name of your organization. If there will be business affiliates who will also be “sellers” of the Technology, please enter their legal names.
If your company has a nine-digit DUNS number, enter it here. If your company does not have a DUNS number, you do not need to provide one.
NAICS Codes can be found in the official 2002 US NAICS Manual North American Industry Classification System—United States, 2002, available from the National Technical Information Service, (800) 553-6847 or (703) 605-6000), or directly from http://www.census.gov/epcd/www/naics.html.
Enter the name of the individual who will serve as the primary point of contact for interactions between your organization and OSAI. Provide a business address and telephone information for this person. OSAI prefers not to use personal or home contact information unless no other contact information is available. Include area codes and any non-U.S. country codes in telephone and fax numbers. If you wish to permit OSAI to correspond with this individual by e-mail, enter a valid e-mail address in the space provided.
The Applicant’s point of contact may be any person you desire to coordinate your application and may include counsel, a representative of management, a technical expert or any other person you consider appropriate for this purpose.
Enter the name and contact information for an alternate point of contact in your organization. OSAI will attempt to contact this person only if it is unable to reach the primary point of contact identified in item R5.
A Pre-Application Consultation is a voluntary means through which OSAI provides helpful guidance to potential applicants without requiring the completion and submission of a full SAFETY Act Application. The Pre-Application Consultation is intended to facilitate a process by which a potential applicant may provide DHS with initial information regarding their Technology, so that DHS may, in turn, provide potential applicants with guidance regarding the submission of an Application for SAFETY Act Designation. The Pre-Application Consultation is also intended to facilitate discussions regarding the SAFETY Act Application process. A Pre-Application Consultation is not a prerequisite for submitting a full application for SAFETY Act Designation.
(Pre-Application Consultation Request Form on following page)
Request for Pre-Application Consultation
Seller Information
P1. Seller Name: __________________________________________________________________
P1.1. Description of Seller. Please provide an overview of your company, including place of incorporation and major affiliates or subsidiaries.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
P2. Non-proprietary Summary
P2.1. Name of your Technology:
P2.2. Technology Description. Provide a non-proprietary overview of your Technology.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
P3. Detailed description of your Technology. In an attachment, please provide a detailed description of your Technology and summarize your Technology’s qualifications for SAFETY Act Designation.
P4. Past and anticipated sales. Note: It may be very important and could significantly expedite your eventual application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state, local or foreign governmental entity.
Who has purchased, utilized or plans to purchase your Technology? (Choose all that apply.)
Federal government (Agency: Approximate Date: )
State government (State: Approximate Date: )
Local government (City/County: Approximate Date: )
Commercial organization (Name: Approximate Date: )
Foreign government (Name: Approximate Date: )
Other (Name: Approximate Date: )
P5. Readiness for Sale. If your Technology has not previously been sold, provide an estimate of when it will be available for sale.
Immediately available for sale
Expected to be available for sales within ____ months. (Fill in the blank.)
P6. Effectiveness
How do you know that your Technology is effective? What kinds of deployment information, test results, independent studies, or other corroborative information could you provide as part of a full Application to support the utility and effectiveness of your Technology? In an attachment, provide a summary of the available information supporting the safety and effectiveness of your Technology. Please indicate any deployments for military or governmental customers. It may be very important and could significantly expedite your eventual application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state, local or foreign governmental entity.
P7. Liability Considerations
In an attachment, please identify the types of potential terrorist activity the Technology is intended to counter. Please describe, to the extent practicable, the scope of damage, loss of life, or other harm that could result from such terrorist activity. Please describe how the Technology has been deployed to date or will be deployed in the future should SAFETY Act Designation be issued.
Instructions for Completing Pre-Application Consultation Form:
Enter the legal name of your organization.
Item P1.1. Please provide a succinct description of your company. Please include the place of incorporation and any major affiliates or subsidiaries who will also be “sellers” of the technology. If your company web site or other publication provides this information, you may provide the web site locator or publication as a response to this question.
Item P2.1. Enter the name of your Technology.
Item P2.2. Please provide a succinct, non-proprietary description of your Technology. When describing your Technology, focus on providing information that will help the Department identify which subject matter technical expert evaluators would be best qualified to review your Technology.
One important purpose of this item is to help the Department recognize potential conflicts of interest and ensure that your application information is not disclosed to evaluators with potential conflicts of interest. The Department is committed to protecting your sensitive business data and may, upon request, describe its protocols for information protection.
Item P3. Description of your Technology
Include as an attachment to your application a summary of your Technology. This summary should be more detailed than your response to P2.2 and may include proprietary or sensitive information. Consider the following questions when preparing your response:
What is your Technology? You may include information you provide to your customers when you sell that Technology.
What is your Technology intended to do?
What are its principal elements, systems, or components?
How does it operate?
How and where may it be utilized?
If your Technology is a service, or incorporates a service, describe the actions, activities, planning, training, and/or expertise involved.
What specific potential to counter terrorism does your Technology have? In particular, what sorts of terrorist attacks or attempted terrorist acts could be deterred, mitigated, or otherwise addressed by your Technology?
Item P4. Past sales
Who has previously purchased or utilized your Technology? What sales do you anticipate? When? Check and complete each line that applies.
Indicate how ready your Technology is to be sold by checking the appropriate box.
Include as an attachment to your application a summary of information available to demonstrate the usefulness and effectiveness of your Technology. The summary information you provide here should include information demonstrating your belief that your Technology can be a valuable counter terrorism tool. The kind of information your summary should include will depend on the nature of your Technology. Please indicate any deployments for military or governmental customers. It may be very important and could significantly expedite your eventual application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state or local governmental entity. Procurements of your Technology by a foreign government may also have significant relevance.
If your Technology is primarily a device or software product, your summary should briefly describe available developmental and operational test data that indicate the likely operating performance of that device or software. This could include performance in past deployments, independent test results, government licenses or certifications, field tests (e.g., performance against simulated attacks), internal test data, customer studies, scientific studies of the techniques involved, industry reports, government or military publications, or any other information that suggests or supports the potential usefulness of your Technology.
If your Technology is primarily a service, your summary should describe the nature and quality of the process or expertise involved and should include any available information of successful past deployments of a similar nature. Indicate whether those involved in providing the QATT have certain specialized training or certifications. In particular, you should also summarize available information that documents any of the following:
The nature and quality of the services you provide.
Your specification (or any governmental specification) for the processes used to provide those services. If formal protocol or processes exist, please describe them.
Your methods for monitoring your adherence to your processes.
Your means for measuring the success of a particular deployment of your services.
Your expertise or reputation as a provider of these services.
Compliance with standards from recognized standard setting organizations.
In an attachment, please identify the types of potential terrorist activity the Technology is intended to address. Please describe, to the extent practicable, the scope of damage, loss of life, or other harm that could result from such terrorist activity. Please describe how your Technology has been deployed to date to counter this type of terrorism or will be deployed in the future should SAFETY Act Designation be issued. Please also describe how deployment of your Technology may be affected should your Technology not receive SAFETY Act Designation. Please include information relating to whether the timing of the deployment of your Technology will be affected.
You need not attach copies of any referenced reports, publications, or other information as part of this Pre-Application. However, be aware that such information should be provided as part of a full Application.
The purpose of completing a SAFETY Act Designation application is for you, the Seller of a Technology, to explain to the Department how your Technology qualifies for the system of risk management and litigation management under the SAFETY Act. The questions are designed to elicit the information that will allow the Department to understand exactly what it is that you sell and how it relates to the criteria for Designation set forth in the Act. Not all questions will be applicable to all types of Technology – this is unavoidable given the broad range of potential types of qualifying Technologies. If a particular request or question does not seem relevant to your Technology, explain why you do not think it is relevant in your response to that item. In addition, the Department will accept any supplemental information regarding your Technology that you wish to provide. It is particularly important to identify any prior use or ongoing procurements of your Technology by the military, Federal Government agencies, or state, local or foreign governmental entities. Prior government use or procurement may significantly expedite the application process.
(SAFETY Act Designation Application Form on following page)
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 address 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 identifier of 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 reference 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.
Registration Information
D3. Registration Status (choose one):
My initial Seller registration is included with this application.
I am updating or correcting previous registration information.
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 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, subsystems 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 very important and could significantly expedite your application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state, local or foreign governmental 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 government (Agency: Approximate Date: )
State government (State: Approximate Date: )
Local government (City/County: Approximate Date: )
Commercial organization (Name: Approximate Date: )
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 entity 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 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 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.
D13. Please describe how your plans for selling, deploying or maintaining your Technology would be affected if the Department does not issue a 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 of 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:
Primary named insured (as it appears on your insurance policy).
Additional named insured relevant to the Technology Sellers.
Type of policy(ies) (e.g., Comprehensive General Liability, Errors and Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.)
Policy Dates. (Start and end)
Insurer.
Per occurrence limits.1
Aggregate limits.
Annual Premium(s).2
Deductible(s) or Self-insured retentions.
Exclusions (please note and explain any pertinent insurance exclusions, cancellation terms, or limits that would potentially dilute or eliminate the availability of coverage under the policies identified in subparagraph “c” above).
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 deployment 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 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 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.
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 person with appropriate information.
D17. 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 form 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 non-publicly 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.
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. |
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Prepared By: |
________________________________ |
Title (if applicable): ____________________ |
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Signature: |
______________________________________________ |
Date: ___/___/20__ |
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The signature of the Preparer must be notarized below: |
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State of: |
_______________ |
County of: |
__________________________ |
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Subscribed and sworn before me this |
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day of |
_____________________ |
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Notary Public: |
___________________________________________________ |
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My Commission Expires on: |
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Instructions for Completing Designation Application Form:
Application Type
If you have not previously filed an Application for SAFETY Act liability protections for this Technology or have not filed a request for Pre-Application Consultation, check “Initial Filing.”
If you have filed a request for Pre-Application Consultation regarding this Technology but have not previously filed an Application for SAFETY Act Designation as a Qualified Anti-Terrorism Technology (QATT), check the second box: “Application following a Pre-Application Consultation.”
If you have previously applied for SAFETY Act liability protections for this Technology, check the third box: “Resubmission of Previous Application.” This case applies if any previous applications for this Technology were withdrawn, found to be incomplete, or were declined. Previously incomplete or declined applications will not affect the evaluation of your current application; this information is requested for administrative and record-keeping purposes only.
If you are filing this form in order to apply for renewal of a Designation, check the fourth box: “Application for Renewal of Designation,” and enter the identification number of the Designation you are renewing as it appeared on your original notification. For renewal applications, you must complete all items but may respond with “No changes” to items that have not changed since your last application for Designation or approved Modification Notice. Wherever you have additional or revised information since your last Designation application or approved Modification Notice, complete that item as directed.
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 address a particular threat, that involve particular types of anti-terrorism Technologies, or for other reasons. If you are requesting an expedited review, please specify the appropriate basis for expedited treatment of your application.
If your Technology is the subject of a pending government procurement or if you are planning to submit a proposal for a procurement decision in the near future, provide the following information to the extent available:
a. Name of procuring organization.
b. Contact information for relevant government procurement official.
c. Related Request for Proposal (RFP) number or other official identifier of the procurement.
d. Upcoming deadlines relating to the procurement (e.g., submission deadline, decision/contract award, etc.).
If your request to expedite falls under a published DHS Notice of Expedited Processing check the appropriate box and follow the published instructions from the announcement.
If your request to expedite is not related to a procurement, please provide the basis for your request and any available supporting information.
Please check the appropriate box relating to your registration status.
Item D3.1. Name of Seller/Applicant
Enter your Seller name as listed on your registration form.
Item D4.1. If this is the first application for this Technology, assign a name to your Technology. This is the name that will appear on any Designation that may be issued.
If you are applying for renewal of an existing Designation, use the name that appears on your most recent Certificate of Designation or Modification Notice.
Item D4.2. The purpose of this item is to help the Department recognize potential conflicts of interest and to avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure.
Provide a brief description of your company, including place of incorporation, a description of your business, and the Technology that is the subject of the Application. When describing your Technology, focus on providing information that will help the Department to identify which subject matter experts would be best qualified to evaluate your Technology. When describing your company, focus on identifying any affiliates that will be involved with your Technology (e.g., parent companies, subsidiaries, joint venture partners, holding companies, etc.).
The purpose of the company description is to help the Department recognize potential conflicts of interest and avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure. Do not include any sensitive or proprietary information in this summary. If you wish to include information on substantially similar QATTs or provide information regarding who your major competitors are with respect to the subject Technology, you may do so.
Please describe the nature of your Technology. The SAFETY Act applies to a broad range of anti-terrorism Technologies. In your response to the question, please describe whether your application is for an anti-terrorism product, service, combination of products and services, information technology or some other form of intellectual property. If your Technology is a product or device, please describe the Technology in detail, including its principal elements, subsystems and components. If your Technology is a service, please describe the nature of the service, the actions, and associated services, 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 “integration” of various products, services, or legacy systems indicate how the Technology will integrate the various component parts.
Item D6.1. What sales of your Technology have you made to date? Identify a representative sale and approximate date for in each category that applies. You may add additional attachments as necessary. Please also specify anticipated sales of your Technology.
Note: It may be very important and could significantly expedite your application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state, local or foreign governmental entity.
Item D6.2. For each Federal, State, or local government agency that has purchased your Technology, provide contact information for one or two points of contact in an attachment. For non-government sales, provide one point of contact. For each federal acquisition, attach a copy of any Request for Proposals or Broad Agency Announcements that led to the award and a copy of your final proposal and Statement of Work.
For each customer, please indicate whether:
The Technology has been fully deployed.
The Technology is in the process of being deployed.
The Technology has been purchased, but deployment has not yet begun.
The deployment is conditional on the Technology earning QATT status.
The Department will assume that any point of contact you provide has been given permission to be contacted by DHS regarding your application.
Item D6.3. Please provide information, if applicable, regarding how the United States Government or any state, local or foreign government has used or is using your Technology. You may also include information relating to your Technology’s use by other entities and commercial deployments undertaken in coordination or conjunction with Federal, State, local, or foreign governments.
Item D6.4. Please identify any determination made by Federal, State, or local government officials that your Technology is effective and appropriate for the purpose of countering terrorism. Such determinations may have been made as part of a government procurement, licensing action or in other contexts. Note: It may be very important and could significantly expedite your application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state, local or foreign governmental entity. As appropriate, you should identify why the previously examined Technology is appropriate for countering acts of terrorism or limiting the harm such acts might otherwise cause.
In certain instances, multiple corporate entities may appropriately be identified as a Seller of the subject Technology. For instance, the Seller of the QATT could include a parent company as well as subsidiaries or other affiliates. Your response will be used to properly identify the Seller(s) of the QATT. If you would like multiple entities to be considered a Seller of the QATT, please clearly and precisely identify each of these firms and identify their respective place of incorporation.
This information will be used to specify the earliest date of sale of the QATT to which the Designation shall apply.
Under the SAFETY Act, the Secretary of the Department of Homeland Security will consider enumerated, nonexclusive criteria in evaluating a Technology for potential Designation as a QATT. The Act gives the Secretary discretion in determining whether to designate a particular technology as a QATT.
This section of the Application requests information that is necessary to evaluate your Technology. Attach your responses to this section as one attachment. Not all questions will be applicable to all types of Technology. If a particular request or question does not seem relevant to your Technology, explain why you do not think it is relevant in your response for that item.
Item D9. Specification of your Technology
One of the most important parts of the application process is precisely defining the scope of your Technology for evaluation and Designation. In order for the Secretary to issue liability protections to your Technology, you must define with a sufficient degree of specificity what that Technology is – that is, what you provide to your customers when you sell that Technology, what it does, how it works, and what aspects of it are invariable from one deployment to the next.
Your description should answer the following questions:
What is your Technology?
What is your Technology intended to do?
What specific potential to counter terrorism does your Technology have? In particular, what sort of terrorist attack could be countered by your Technology?
How and where may your Technology be utilized?
How does your Technology counter terrorism? Explain the underlying principles or properties that allow your Technology to perform its functions and achieve its purposes. If your Technology consists of devices, explain the operational principles of those devices. If your Technology consists of services, explain how those services are implemented to ensure consistent quality wherever they are delivered and whether these services conform to recognized industry standards. If your Technology consists of software, explain the key features and algorithms. If your Technology consists of some other kind of product, explain how you produce that product. This information will help the Department to understand the precise scope of the Technology for which you are applying for SAFETY Act coverage.
What are the important elements that make up your Technology? That is, what are the component processes, devices, software, or other contributing activities and technologies that will be included in your specification? How are they defined or delineated? Be aware that any ancillary components of your Technology that are identified in your specification (e.g., manuals, training, maintenance, etc.) should be accompanied by sufficient information to evaluate them. What parts of your business, if any, are explicitly not included in this specification for purposes of this application?
Examples of component systems and activities of your Technology might include:
Equipment
Software
Software design
Personnel training and qualifications
Staffing
Algorithms
Consulting services
Systems integration services
Decision support systems or services
Maintenance contracts
Periodic upgrades, post-deployment reviews
Testing services
Quality control features
If your Technology is primarily service-based, focus on describing the various activities and sub-processes that contribute to the overall process of delivering your service(s). This information will help the Department understand the precise scope of your Technology.
In addition to describing what you do, you should also describe any elements, processes, or activities that complement or interact with your Technology but that are not part of the Technology you are specifying in this application. These might include other technologies you sell, activities performed by your customers, technologies provided by other vendors, or parts of the public infrastructure. This information will help the Department to understand the precise scope of Technology you are establishing in this specification. If your technology helps to integrate new components with legacy systems, please so indicate.
Describe the sequence of steps involved in providing your Technology to a customer, from initial contact to final deployment. Focus your description on the process of producing and deploying your Technology, as opposed to the end result or the nature of any specific tangible deliverable. Where possible, include the estimated time required for each activity or step.
If your Technology involves physical products, your discussion might include elements such as:
Production, including quality assurance
Installation and configuration
Operation
Training, including any user manuals or terms of use
Maintenance
Monitoring
Upgrades
Warranties and service contracts
Quality Control
Where your Technology involves services, your description might include (as relevant):
Customer requirements analysis
Determining scope of effort
Staffing
Operation
Training
Implementation
Post-delivery support
Documentation
Quality Control
In the case of ongoing services, you should also discuss (as relevant):
Monitoring
Managing staff turnover
Managing change requests
Process quality control
If your Technology is not yet being marketed, estimate the time before your Technology will be available for sales or will be selling at your planned maximum rate. You should include any anticipated delays due to funding, required marketing, required licenses or certifications, tooling, staffing, subcontractor delays, etc.
If your Technology is already deployed, describe the deployments. Your description should include the circumstances and the nature of the deployment of your Technology. Provide sufficient information about the scope of the deployment that addresses the following questions: (1) Has it already been deployed? (2) Is it being deployed? (3) Has it been purchased for deployment in the future? Information could also include the length of the deployment, the purpose of the deployment (testing versus general use), and the types of customers using the Technology.
Please provide an assessment of the magnitude of risk to the public form the type of terrorist activities your Technology would counter. Your response should identify the types or categories of potential terrorist activities your Technology is intended to address. Your response should also present, to the extent practicable, estimates of the scope of the injury, property damage, economic loss, damage, loss of life, or other harm, including financial harm, that could result from such terrorist activity. Additionally, please describe how the Technology has been deployed to date to counter such terrorist threats.
Please describe how your plans for selling or deploying your Technology would be affected should the SAFETY Act’s system of risk and litigation management not be made available. Please describe how the Technology will be deployed in the future if SAFETY Act Designation is issued. Within the response, please address how current and future deployments of your Technology would be affected without SAFETY Act protections. To the extent possible, include the likely effects of the excessive costs of insurance on the price of the product, and the possible consequences thereof on development, marketing, manufacture, qualification, sale, transportation, use, operation, and support of the Technology.
The information you provide here should include information supporting your belief that your Technology can be a valuable counter terrorism tool. The kind of documentation you provide will depend on the nature of your Technology.
If your Technology is primarily a device or software product, your documentation should emphasize available developmental and operational test data that indicate the likely operating performance of that device or software. This could include performance in past deployments, independent test results, government licenses or certifications, field tests (e.g. performance against simulated attacks), internal test data, customer studies, scientific studies of the techniques involved, industry reports, government or military publications, or any other documentation or experience that suggests or supports the potential usefulness of your Technology. Please attach copies of any such reports, publications, or evidence by using the additional attachments sections that would facilitate analysis and evaluation at your Technology by subject matter experts.
If your Technology is primarily a service, your documentation should emphasize the quality of the process whereby that service is delivered and should include any available evidence of successful past deployments of a similar nature. In particular, you should provide or cite information that documents any of the following:
The quality of the services you provide.
Your specification for the processes you use to provide those services.
The repeatability of your processes for providing those services.
Your methods for monitoring your adherence to your processes and in preserving quality.
Your means for measuring the success of a particular deployment of your services.
Your experience as a provider of these services.
The Department will not ordinarily conduct tests of your Technology for purposes of SAFETY Act evaluation nor compare your Technology directly to other similar technologies. Reviewers will evaluate your Technology against the statutory criteria for Designation primarily on the basis of the information you provide. Accordingly, the information you provide in response to this question should be as comprehensive and thorough as possible. It may be very important and could significantly expedite your application if your Technology has been acquired or utilized (or is subject to an ongoing procurement) by the military, a Federal government agency, or a state or local governmental entity. Procurements of your Technology by a foreign government may be relevant.
Please provide an overview narrative of your Technology, including references and summaries of supporting documentation. If you reference any material that is not publicly available, it should be included as an attachment to your application. If you refer to information provided elsewhere in your application, cite it by internal title, item number, and the name of the attachment. Even though your entire application will be treated as confidential, you may (but are not required to) specially mark those portions of your application which contain proprietary and/or business confidential information.
If you wish, you may use this item to summarize in broad terms why you believe your Technology qualifies for SAFETY Act Designation. Please provide whatever additional information that would be helpful to the Department in analyzing and evaluating your Technology. You may refer to the specific criteria of the Act, or suggest other relevant criteria, as you see fit.
Item D16. Insurance Data
Document any and all current insurance coverage that would be available to satisfy otherwise compensable third party claims arising out of or relating to or resulting from an act of terrorism were your Technology deployed in defense against or response to or recovery from such an act and found to have caused harm. Please state whether such policy includes TRIA coverage, as amended, or other insurance policy(ies) provisions or endorsements that cover acts of terrorism. Please specify if any relevant exclusions or cancellation provisions that would limit the availability of the current policies to satisfy third party claims. Please also ensure that the insurance coverage for all of the Sellers listed in D.7. is contained in the answers to the items below. In doing so, please be certain to specify whether the Seller(s) is/are the primary insured or an additional insured.
Item D16.1. Current Insurance
For item 16.1a, provide the name of the company identified as the primary insured for the relevant current policy. If you are an additional insured instead of the primary policy holder, please identify the primary insured and each other firm identified as an additional named insured in item 16.1.b.
In item 16.1.k., specify the type of terrorism coverage provided under the referenced policy(ies) (e.g., Terrorism Risk Insurance Extension Act, as amended, other coverage, no terrorism exclusion). Please specify the overall and per occurrence limits that would apply to the terrorism coverage.
Item D16.2. Unavailability of Insurance
The SAFETY Act provides that a Seller may not be required “to obtain liability insurance of more than the maximum amount of liability insurance reasonably available from private sources on the world market at prices and terms that will not unreasonably distort the sale price of Seller’s anti-terrorism technologies.” If you are unable to obtain appropriate insurance, please provide information concerning your attempts to obtain insurance coverage for your Technology (e.g., written communications from insurance companies or brokers explaining why you Technology cannot be insured). If insurance is available for terrorism events but at rates which would distort the sales price of your Technology, document the prices of that insurance and provide the relevant information to support how it would affect the price of your Technology. You may wish to contact OSAI with questions concerning what information would be most helpful to provide in response to this item. 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 odes arise later in the process, the Applicant may submit appropriate information at that time.
Item D16.3. Insurance Point of Contact
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 person with appropriate information.
Certain financial data may be utilized in the process for analyzing the appropriate amount of insurance coverage for your particular Technology. This is particularly true when questions arise as to whether insurance costs unduly distort the price of your Technology. Accordingly, you may be requested to provide certain financial data to OSAI as part of your application. That said, OSAI will not demand financial information when it is not necessary for a particular application, and will not disclose sensitive or proprietary information outside the application process. Applicants may wish to provide financial data relating exclusively to the Technology.
Item D17.1. It may be helpful to attach your latest financial statement. If you are a public company, your latest SEC 10-K annual report and SEC 10-Q quarterly report, together with any amendments thereto, should suffice. If your company is not publicly traded, 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.
In the process of answering the questions above, you might find it useful to attach additional documents in support of your answers. These items can be included in your application by using the “Additional Attachments” feature. When answering the items above, it is appropriate to refer to attachments by name and or number. Examples of common attachments might include, but are not limited to, the following: test reports demonstrating the effectiveness of the Technology, operating manuals, training manuals, project/program management plans, quality assurance plans, quality control plans, copies of company certifications, results from pilot studies, testimonials from customers, and warranties.
Declaration for Written Submissions
An authorized agent of the applicant must, in the presence of a Notary, sign and date this form before submitting it to OSAI. For electronic submissions or web submissions, follow the instructions provided at safetyact.gov.
SAFETY Act Certification provides Sellers of a QATT with an additional measure of liability protection. The Sellers of Technologies that receive SAFETY Act Certification are entitled to all of the liability protections that accompany SAFETY Act Designation as well as the rebuttal presumption that the government contractor defense applies to claims arising out of, relating to, or resulting from an Act of Terrorism. In addition, QATTs that received Certification will be placed on the Approved Products List for Homeland Security.
A Certification application may be submitted along with a Designation application or may be submitted after SAFETY Act Designation has been issued. However, a Technology may not receive Certification without having first received Designation.
To receive SAFETY Act Certification, the Department must conclude that the Technology “will perform as intended, conforms to the Seller’s specifications, and is safe for use as intended.”3
(Application Form on following page)
Application for SAFETY Certification
Application Type
C1. Type of Application. This application is a(n) (choose one):
Initial Application Filing for a Certification, please provide Designation Application ID#___________________________________________
Resubmission of a Previous Application for Certification, please provide Designation Application ID #: ________________________
Expedited Review
C2. 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 Department may conduct expedited processing for applications that are the subject of a pending or past Federal, State or local procurement, that address a particular threat, that involve particular types of anti-terrorism Technologies or for other reasons. Depending on the nature of the procurement, this may substantially expedite and simplify the application process. 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 the relevant government procurement official;
c. The related Request for Proposal (RFP) number or other official identifier of 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 reference number for such notice and a brief statement as to why your application falls within the scope of the Notice of the Expedited Processing. If you wish to provide other bases for expedited processing please specify.
Registration Information
C3. Registration Status (choose one):
I am updating or correcting previous registration information.
My previously provided registration information is still accurate:
C3.1.
Seller Name:
Certification
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.
C4. Performs as Intended. Define what it means for your Technology to perform as intended, and provide information and/or data establishing that your Technology performs as intended. This information may be the same as or in addition to information provided for an Application for SAFETY Act Designation.
C5. Conforms to Seller’s Specifications. Describe the processes and procedures you use to ensure that each sale of your Technology conforms to the applicable specifications. If your Technology was or is involved in a government procurement, acceptance of the Technology by the government and related testing may be highly relevant here. Provide available documentation demonstrating that your Technology conforms to established specifications.
C6. Safe for use as intended. Provide available analyses evidencing that the Technology is safe for use as intended. Please note any known or suspected hazards or safety risks associated with your Technology. Please provide safety and hazard analyses for your Technology
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. |
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Prepared By: |
________________________________ |
Title (if applicable): ____________________ |
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Signature: |
______________________________________________ |
Date: ___/___/20__ |
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The signature of the Preparer must be notarized below: |
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State of: |
_______________ |
County of: |
__________________________ |
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Subscribed and sworn before me this |
_____ |
day of |
_____________________ |
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Notary Public: |
___________________________________________________ |
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My Commission Expires on: |
________________________________________ |
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Instructions for Completing Certification Application Form:
If you have not previously filed an Application for SAFETY Act Certification for this Technology, check “Initial Filing.”
If you have previously applied for SAFETY Act Certification for this Technology, check the second box: “Resubmission of Previous Application for Certification.” This case applies if any previous applications for this Technology were found to be incomplete, were withdrawn, or were declined. Previously incomplete or declined applications will not adversely affect the evaluation of your current application. This information is requested for administrative and record-keeping purposes only.
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 or past Federal, State or local procurement, that address a particular threat, that involve particular types of anti-terrorism Technologies, or for other reasons. If you are requesting an expedited review, please specify the appropriate basis for expedited treatment of your application.
If your Technology is the subject of a pending government procurement or if you are planning to submit a proposal for a procurement decision in the near future, provide the following information to the extent available:
a. Name of procuring organization.
b. Contact information for relevant government procurement official.
c. Related Request for Proposal (RFP) number or other official identifier of the procurement.
d. Upcoming deadlines relating to the procurement (e.g., submission deadline, decision/contract award, etc.).
If your request to expedite falls under a published DHS Notice of Expedited Processing, please provide such notice’s reference number and follow the instructions set forth in the announcement.
If your request to expedite is not related to a procurement, please provide the basis for your request and provide available supporting information.
Please check the appropriate box relating to your registration status.
Item C3.1. Name of Seller/Applicant
Enter your Seller name as listed on your registration form.
Provide support for the claim that your Technology will perform as intended. Explain what it means for your Technology to perform as intended and include information demonstrating that the Technology will, under reasonable circumstances, consistently perform as intended over time. This information may be the same as or in addition to information provided for an Application for SAFETY Act Designation.
The kind of documentation you should provide will depend on the nature of your Technology. If your Technology is primarily a device or software product, then your documentation should emphasize the likely operating performance of that device or software. This will require that you demonstrate that your Technology is effective for its intended use AND that it will perform reliably. You may consider providing information regarding the continuing ability of your Technology to perform and be used in accordance with specifications. Such specifications could include, for instance, elements such as detection limits, mean time between failures, probability of detection, false positive/negative rates, or other metrics. You may include, for instance, any government acceptance testing, third party evaluations, or other objective data. Measures of effectiveness include evidence of quality control plans, reliability data, evidence of reproducibility between deployments, and evidence that customers can install, use, and maintain the system. This might include procedures to test your Technology over time. The Technology might also have defined performance specifications that are consistently met while the Technology is in operation.
If your Technology is primarily a service, you should provide information on the effectiveness of the core capabilities of the service. Such information may be provided through documentation of past deployments of the Technology as a whole or through the completion of substantially similar projects through other means.
Information supporting the effectiveness of your service could include such items as sound quality assurance processes, internal or external auditing services to ensure that the processes remain current, performance review strategies, employee screening procedures and certification requirements, documented practices of updating employee training, processes for maintaining currency of training and intelligence information, and the like. If you have successfully deployed the Technology or a substantially similar project multiple times with success (i.e., testimonials, independent assessments, etc.), then you may provide this information as evidence of the performance of your Technology. You may, when applicable, demonstrate reproducibility by adherence to well-recognized national or international standards.
You may include as an attachment to your application the supporting or referenced material that is not publicly available. If you refer to information provided elsewhere in your application, cite it by internal title, item number, or the name of the attachment.
Provide support for the claim that your Technology conforms (and will continue to conform) to the applicable specifications. For products, technical specifications should include those things that are invariable from deployment to deployment, such as size, weight, or services provided with the sale of the product (maintenance, warranties, etc.). Consideration should be given to things like compliance with manufacturing standards, factory acceptance testing procedures, site acceptance testing procedures, quality control processes and procedures, and quality assurance plans. Government acceptance of your Technology and related testing may be highly relevant to this factor.
For services, specifications might consist of the processes and procedures that dictate the implementation of the service. Such processes could be given in a standard operating procedure document or a process manual. You might also supply this support through a “Statement of Work” or through a response to a “Request for Proposal.” Additionally, you should provide information that a process is in place to ensure conformity to those specifications, such as a well-defined quality assurance plan or adherence to applicable industry standards. In cases where standards do not exist or apply you should show some mechanism to ensure conformity to specifications, such as periodic internal or external reviews of the service’s fundamental processes. Again, government acceptance/use of your Technology may be highly relevant.
Your response may consist of an overview narrative including references and summaries of supporting documentation. You may include as an attachment to your application any of the supporting or referenced material that is not publicly available. The Department requires this information in order to perform its comprehensive review of the design of your Technology to determine whether it conforms to your specifications.
Please provide information that your Technology is safe for use as intended. Provide a safety and hazard analysis for your Technology.
The SAFETY Act (6 USC § 442(d)(2)) requires that the Seller conduct and provide to the Department safety and hazard analyses for Technology being considered for SAFETY Act Certification. Your safety and hazard analyses should discuss:
Documentation pertaining to the safety of your Technology.
Known hazards associated with any part of the lifecycle of your Technology.
Any potential hazards to your employees.
Any potential hazards to the purchasers or operators of your Technology.
Any potential hazards to third parties.
Potential hazards arising from the Technology’s deployment in the event of an Act of Terrorism.
Potential hazards arising in the event of a false alarm.
Potential hazards arising from improper deployment, use, or maintenance of the Technology.
Your response may also include an overview narrative, including references and summaries of supporting documentation. You may include as an attachment to your application any of the supporting or referenced material that is not publicly available.
In the process of answering the questions above, you might find it useful to attach additional documents in support of your answers. These items can be included in your application by using the “Additional Attachments” feature. When answering the items above, it is appropriate to refer to attachments by name and/or number. Examples of common attachments might include, but are not limited to, the following: test reports demonstrating the effectiveness of the Technology, operating manuals, training manuals, project/program management plans, quality assurance plans, quality control plans, copies of test reports demonstrating effectiveness, results from pilot studies, testimonials from customers, and warranties. The Department will also accept any supplementary information concerning your Technology that you feel will be helpful to the Department in analyzing your Technology.
Declaration for Written Submissions
An authorized agent of the applicant must, in the presence of a Notary, sign and date this form before submitting it to OSAI. For electronic submissions or web submissions, follow the instructions provided at safetyact.gov.
To encourage the development of anti-terrorism technologies, the SAFETY Act implementing regulations provide for the issuance of Developmental Testing and Evaluation Designations (DT&E Designations) for promising anti-terrorism technologies. DT&E Designation facilitates the deployment of these anti-terrorism technologies in the field either for test and evaluation purposes or in response to exigent circumstances by providing, on a limited basis, the liability protections offered by the SAFETY Act. Depending on the nature and/or the maturity of the Technology, operational or other conditions may be placed on the availability of SAFETY Act liability protections. DT&E Designations are intended to provide the Department with added flexibility in making the SAFETY Act liability protections available to firms that are developing promising anti-terrorism technologies.
(Application Form on following page)
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:
Overview of The Anti-Terrorism Technology
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, systems 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.
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Developmental Testing and Evaluation Designation
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.
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.
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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. Deployment and Operation. Describe the sequence of steps involved in deploying and operating your Technology.
TE8. Magnitude of Risk. Please provide an assessment of the magnitude 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 activity. 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 acts 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 evaluating your anti-terrorism technology. Please include information relating to interest by governmental entities in testing or provisionally deploying your Technology.
TE12. Insurance Data.
TE121 Please provide the information below for any 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:
Primary Named Insured (as it appears on your insurance policy).
Additional named insured relevant to the Technology Sellers.
Type of policy(ies) (e.g., Comprehensive General Liability, Errors and Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.) and any relevant endorsements.
Policy Dates. (Start and end)
Insurer.
Per occurrence limits.4
Aggregate limits.
Annual Premium(s).5
Deductible(s) or Self-insured retentions.
Exclusions (please note and explain any pertinent insurance exclusions or cancellation terms that would potentially dilute or eliminate the availability of coverage of any of the policies identified in subparagraph “c” above).
Does your insurance policy(ies) cover the type of developmental test and evaluation and activities anticipated in this application? If yes, please describe.
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 deployment 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.
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.
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 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.
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 your 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-publicly 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.
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. |
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Prepared By: |
________________________________ |
Title (if applicable): ____________________ |
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Signature: |
______________________________________________ |
Date: ___/___/20__ |
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The signature of the Preparer must be notarized below: |
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State of: |
_______________ |
County of: |
__________________________ |
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Subscribed and sworn before me this |
_____ |
day of |
_____________________ |
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Notary Public: |
___________________________________________________ |
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My Commission Expires on: |
________________________________________ |
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Instructions for Completing Developmental Testing and Evaluation Designation Application Form:
If you have not previously filed an Application for SAFETY Act liability protections for this Technology or have not filed a request for Pre-Application Consultation, check “Initial Filing.”
If you have filed a request for Pre-Application Consultation regarding this Technology but have not previously filed an Application for SAFETY Act liability protections, check the second box: “Application following a Pre-Application Consultation.”
If you have previously applied for SAFETY Act liability protections for this Technology, check the third box: “Resubmission of Previous Application.” This case applies if any previous applications for this Technology were withdrawn, found to be incomplete, or were declined. Previously incomplete or declined applications will not affect the evaluation of your current application; this information is requested for administrative and record-keeping purposes only.
Please check the appropriate box relating to your registration status.
Item TE2.1. Name of Applicant/Seller
Enter your Seller name as listed on your registration form.
Item TE3.1. If this is the first application for this Technology, assign a name to your Technology. This is the name that will appear on Developmental Testing and Evaluation Designation that may be issued.
Item TE3.2. The purpose of this item is to help the Department recognize potential conflicts of interest and to avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure.
Provide a brief description of your company, including the place of incorporation, a description of your business, and the Technology that is the subject of this Application. When describing your Technology, focus on providing information that will help the Department to identify which subject matter experts would be best qualified to evaluate your Technology. When describing your company, focus on identifying any affiliates that will be involved with your Technology (e.g., parent companies, subsidiaries, joint venture partners, holding companies, etc.).
The purpose of the company description is to help the Department recognize potential conflicts of interest and avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure. Do not include any sensitive or proprietary information in this summary. If you wish to include information on substantially similar QATTs or provide information regarding who your major competitors are with respect to the subject Technology, you may do so.
Please describe the nature of your Technology. The SAFETY Act applies to a broad range of anti-terrorism Technologies. In your response to the question please describe whether your application is for an anti-terrorism product, service, combination of products and services, information technology or some other form of intellectual property. If your Technology is a product or device, please describe the Technology in detail, including its principal elements, subsystems 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.
Developmental Testing and Evaluation Designation
Under the SAFETY Act, the Secretary of the Department of Homeland Security will consider enumerated, non exclusive criteria when evaluating a Technology for potential Developmental Testing and Evaluation Designation. The Act gives the Secretary discretion in determining whether to issue a Developmental Testing and Evaluation for a Technology.
This section of the Application requests information that is necessary to evaluate your Technology. Attach your responses to this section as one attachment. Not all questions will be applicable to all types of Technology. If a particular request or question does not seem relevant to your Technology, explain why you do not think it is relevant in your response for that item.
Item TE5. Specification of your Technology
One of the most important parts of the application process is precisely defining the scope of your Technology for evaluation and Developmental Testing and Evaluation Designation. In order for the Department to issue liability protections to your Technology, you must define with a sufficient degree of specificity what that Technology is – that is, what you provide to your customers when you sell that Technology, what it does, how it works, and what aspects of it are invariable from one deployment to the next.
Your description should answer the following questions:
What is your Technology?
What is your Technology intended to do?
What specific potential to counter terrorism does your Technology have? In particular, what sorts of terrorist attack or attempted terrorist act could be countered by your Technology?
How and where may it be utilized?
How does your Technology counter terrorism? Explain the underlying principles or properties that allow your Technology to perform its functions and achieve its purposes. If your Technology consists of devices, explain the operational principles of those devices. If your Technology consists of services, explain how those services are implemented to ensure consistent quality wherever they are delivered and whether these services conform to recognized industry standards. If your Technology consists of software, explain the key features and algorithms. If your Technology consists of some other kind of product, explain how you produce that product. This information will help the Department to understand the precise scope of the Technology for which you are applying for SAFETY Act coverage.
What are the important elements that make up your Technology? That is, what are the component processes, devices, software, or other contributing activities and technologies that will be included in your specification? How are they defined or delineated? What parts of your business, if any, are explicitly not included in this specification for purposes of this application?
Examples of component systems and activities of your Technology might include:
Equipment
Software
Software design
Personnel training and qualification
Staffing
Algorithms
Consulting services
Systems integration services
Decision support systems or services
Maintenance contracts
Periodic upgrades, post-deployment reviews
Testing services
Quality control features
If your Technology is primarily service-based, focus on describing the various activities and sub-processes that contribute to the overall process of delivering your service(s). This information will help the Department understand the precise scope of your Technology.
In addition to describing what you do, you should also describe any elements, processes, or activities that complement or interact with your Technology but that are not part of the Technology you are specifying in this application. These might include other technologies you sell, activities performed by your customers, technologies provided by other vendors, or parts of the public infrastructure. If your Technology helps to integrate new components with legacy systems, please so indicate. This information will help the Department to understand the precise scope of Technology you are establishing in this specification.
Item TE6. Nature of Test Scenario.
Please provide us with an outline of the test plan. The outline should include the nature of the test, the entity that will conduct the test, time frame, proposed test methodology, location of the test and summary rationale for conducting the test. Please include information relating to government or government sponsored testing of your Technology.
Describe the sequence of steps involved in providing your Technology to a customer, from initial contact to final deployment. Focus your description on the process of producing and deploying your Technology, as opposed to the end result or the nature of any specific tangible deliverable. Where possible, include the estimated time required for each activity or step.
If your Technology involves physical products, your discussion might include elements such as:
Production, including quality assurance
Installation and configuration
Operation
Training, including any user manuals or terms of use
Maintenance
Monitoring
Upgrades
Warranties and service contracts
Quality control
Where your Technology involves services, your description might include (as relevant):
Customer requirements analysis
Determining scope of effort
Staffing
Operation
Training
Implementation
Post-delivery support
Quality Control
In the case of ongoing services, you should also discuss (as relevant):
Monitoring
Managing staff turnover
Managing change requests
Process quality control
Please provide an assessment of the magnitude of risk to the public from the type of terrorist activities your Technology would counter. Your response should identify the types or categories of potential terrorist activities your Technology is intended to address. Your response should also present, to the extent practicable, estimates of the scope of the injury, property damage, economic loss, damage, loss of life, or other harm, including financial harm, that could result from such terrorist activity. Additionally, please also describe how the Technology has been deployed to date, if applicable to counter terrorist threats.
Please describe how your plans for selling or deploying your Technology would be affected should the SAFETY Act’s system of risk and litigation management not be made available. Please describe how the Technology will be deployed in the future if SAFETY Act Developmental Testing and Evaluation Designation is issued.
The information you provide here should include the primary information supporting your belief that your Technology can be a valuable counter terrorism tool. The kind of documentation you provide will depend on the nature of your Technology.
If your Technology is primarily a device or software product, then your documentation should emphasize available developmental and operational test data that indicate the likely operating performance of that device or software. This could include performance in past deployments, independent test results, field tests (e.g. performance against simulated attacks), internal test data, customer studies, scientific studies of the techniques involved, industry reports, government or military publications, or any other documentation that suggests or supports the potential usefulness of your Technology. Please attach copies of any such reports, publications, or evidence by using the additional attachments sections that would facilitate analysis and evaluation of your Technology by subject matter experts.
If your Technology is primarily a service, your documentation should emphasize the quality of the process whereby that service is delivered and should include any available evidence of successful past deployments of a similar nature. In particular, you should provide or cite information that documents any of the following:
The quality of the services you provide.
Your specification for the processes you use to provide those services.
The repeatability of your processes for providing those services.
Your methods for monitoring your adherence to your processes.
Your means for measuring the success of a particular deployment of your services.
Your reputation as a provider of these services.
The Department will not ordinarily conduct any tests of your Technology for purposes of SAFETY Act evaluation nor compare your Technology directly to other similar technologies. Reviewers will evaluate your Technology against the criteria for Developmental Testing and Evaluation Designation primarily on the basis of the information you provide. Accordingly, the information you provide in response to this question should be as comprehensive as possible.
Please provide an overview narrative of your Technology, including references and summaries of supporting documentation. If you reference any material that is not publicly available, it should be included as an attachment to your application. If you refer to information provided elsewhere in your application, cite it by internal title, item number, and the name of the attachment. Even though your entire application will be treated as confidential, you (but are not required to) specially mark those portions of your application which contain proprietary and/or business confidential information.
If you wish, you may use this item to summarize in broad terms why you believe your Technology qualifies for SAFETY Act Developmental Testing and Evaluation Designation. Please provide whatever additional information that would be helpful to the Department in analyzing and evaluating your Technology.
Item TE12. Insurance Data
Document any and all current insurance coverage that would be available to satisfy otherwise compensable third party claims arising out of, or relating to, or resulting from an act of terrorism were your Technology deployed in defense against or response to or recovery from such act and found to have caused harm. Please state whether such policy includes TRIA coverage, as amended, or other insurance policy(ies) provisions or endorsements that cover acts of terrorism. Please specify if any relevant exclusions or cancellation provisions that would limit the availability of the current policies to satisfy third party claims.
Item TE12.1. Current Insurance
For item TE12.1.a, provide the name of the company identified as the primary insured for the relevant current policy. If you are an additional insured instead of the primary policy holder, please identify the primary insured and each other firm identified as an additional named insured in item TE12.1.b.
In item TE12.1.k., specify the type of terrorism coverage that is provided under the specified policy(ies) (e.g., Terrorism Risk Insurance Extension Act, as amended, other coverage, no terrorism exclusion). Please specify the overall and per occurrence limits that would apply to the terrorism coverage.
Item TE12.2. Unavailability of Insurance
The SAFETY Act provides that a Seller may not be required “to obtain liability insurance of more than the maximum amount of liability insurance reasonably available from private sources on the world market at prices and terms that will not unreasonably distort the sale price of Seller’s anti-terrorism technologies.” If you are unable to obtain appropriate insurance, please provide information concerning your attempts to obtain insurance coverage for your Technology (e.g., written communications from insurance companies or brokers explaining why your Technology cannot be insured). If insurance is available for terrorism events but at rates which would distort the sales price of your Technology, document the prices of that insurance and provide information to support how it would affect the price of your Technology. You may wish to contact OSAI with questions concerning what information would be most helpful to provide in response to this item.
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.
Certain financial data may be utilized in the process for analyzing the appropriate amount of insurance coverage for your particular Technology. This is particularly true when questions arise as to whether insurance costs unduly distort the price of your Technology. Accordingly, you may be requested to provide certain financial data to OSAI as part of your application. That said, OSAI will not demand financial information when it is not necessary for a particular application, and will not disclose sensitive or proprietary information outside the application process. Applicants may wish to provide financial data relating exclusively to the Technology.
Item TE13.1. It may be helpful to attach your latest financial statement. If you are a public company, your latest SEC 10-K annual report and SEC 10-Q quarterly report together with any amendments thereto should suffice. If your company is not publicly traded, you may include the following information for the most recent fiscal year: income statement, state of cash flow, balance sheet, and pro-forma financial statement. OSAI may seek additional and more specific information but only when necessary for a particular application.
In the process of answering the questions above, you might find it useful to attach additional documents in support of your answers. These items can be included in your application by using the “Additional Attachments” feature. When answering the items above, it is appropriate to refer to attachments by name and or number. Examples of common attachments might include, but are not limited to, the following: test reports demonstrating the effectiveness of the Technology, operating manuals, training manuals, project/program management plans, quality assurance plans, quality control plans, copies of company certifications, results from pilot studies, testimonials from customers, and warranties.
Declaration for Written Submissions
An authorized agent of the applicant must, in the presence of a Notary, sign and date this form before submitting it to OSAI. For electronic submissions or web submissions, follow the instructions provided at safetyact.gov.
The Secretary may issue Block Designations at his discretion for anti-terrorism technologies that meet established performance standards or defined technical characteristics. Block Designation will be published on the SAFETY Act Web site (http://www.safetyact.gov) Sellers of Technologies that are subject of a Block Designation may submit a streamlined application to be afforded the liability protection available under the SAFETY Act.
Each Block Designation may set forth particular terms and conditions; however, the accompanying application form should be utilized for Sellers applying for SAFETY Act protection pursuant to a particular Block Designation.
(Application Form on following page)
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.
Previous Application ID #: _____________________Reference: ________________ 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.
BD.5 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.
BD.6 Provide the earliest date of sale of the Technology for which you are requesting SAFETY Act coverage.
BD.7 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.
BD.8 Submit information demonstrating your Technology’s conformance with the technical specifications or standards of the Block Designation.
BD.9 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.
BD11.1 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 were your Technology deployed in defense against or in response or recovery from such act:
Primary Named Insured (as it appears on your insurance policy).
Additional named insured relevant to the Technology Sellers.
Type of policy(ies) (e.g., Comprehensive General Liability, Errors and Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.) and any relevant endorsements.
Policy Dates. (Start and end)
Insurer.
Per occurrence limits.6
Aggregate limits.
Annual Premium(s).7
Deductible(s) or Self-insured retentions.
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).
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 deployment 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.
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 indicating whether the policy covers SAFETY Act claims; if so, please provide a copy of such document.
BD11.2 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.
BD11.3 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 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 form the Applicant if necessary during the Application process
BD12.1 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-publicly 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.
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. |
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Prepared By: |
________________________________ |
Title (if applicable): ____________________ |
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Signature: |
______________________________________________ |
Date: ___/___/20__ |
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The signature of the Preparer must be notarized below: |
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State of: |
_______________ |
County of: |
__________________________ |
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Subscribed and sworn before me this |
_____ |
day of |
_____________________ |
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Notary Public: |
___________________________________________________ |
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My Commission Expires on: |
________________________________________ |
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Instructions for Completing Block Designation Application Form:
See www.safetyact.gov for instructions on which of the following items to fill out in response to a given Block Designation notice.
Check the appropriate box and provide that requested information
Check the appropriate box indicating your registration status.
Item BD3. Name of Seller/Applicant
Please provide the legal name of the Seller/applicant.
Item BD4. Company Description
The purpose of this item is to help the Department recognize potential conflicts of interest and to avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure.
Provide a brief description of your company, including place of incorporation, a description of your business, and the Technology that is the subject of the Application. When describing your Technology, focus on providing information that will help the Department to identify which subject matter experts would be best qualified to evaluate your Technology. When describing your company, focus on identifying any affiliates that will be involved with your Technology (e.g., parent companies, subsidiaries, joint venture partners, holding companies, etc.).
The purpose of the company description is to help the Department recognize potential conflicts of interest and avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure. Do not include any sensitive or proprietary information in this summary. If you wish to include information on substantially similar QATTs or provide information regarding who your major competitors are with respect to the subject Technology, you may do so.
Item BD5. Seller
In certain instances, multiple corporate entities may appropriately be identified as a Seller of the subject Technology. For instance, the Seller of the QATT could include a parent company as well as subsidiaries or other affiliates. Your response will be used to properly identify the Seller(s) of the QATT. If you would like multiple entities to be considered a Seller of the QATT, please clearly identify these firms and identify their respective place of incorporation.
This information will be used to specify the earliest date of sale of the QATT to which the Designation shall apply (note this date may be prior to the effective date of the Designation).
Item BD7. Identification of Block Designation
Please identify the Block Designation you are responding to by noting the name of the Block Designation and that date it was issued. Reference any special terms or conditions presented in the referenced Block Designation.
Item BD8. Compliance with Technical Specifications
In order for the Under Secretary to extend SAFETY Act protections to your Technology, please provide sufficient information to demonstrate that your Technology complies the technical specifications of the referenced Block Designation. Please be specific.
Please demonstrate how your Technology complies with the terms and conditions stated in the referenced Block Designation. Please be specific and provide sufficient detail.
Item BD10. Other Information
Please provide other information that may help the Department as it considers your application. This may include information demonstrating the Technology’s effectiveness, utility, and readiness for sale.
Item BD11. Insurance Data
Document any and all current insurance coverage that would be 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 and found to have caused harm. Please state whether such policy includes TRIA coverage, as amended, or other insurance policy(ies) provisions or endorsements that cover acts of terrorism. Please specify if any relevant exclusions or cancellation provisions would limit the availability of the current policies to satisfy third party claims. Please also ensure that the insurance coverage for each of the Sellers listed in BD3. is contained in the answers to the items below. In doing so, please be certain to specify whether the Seller is the primary insured or an additional insured.
Item BD11.1. Current Insurance
For item 11.1.a , provide the name of the company identified as the primary insured for the relevant current policy. If you are an additional insured instead of the primary policy holder, please identify the primary insured and each other firm identified as an additional named insured in item 11.1.b.
In item 11.1.c., what type of terrorism coverage applies to this policy (e.g., Terrorism Risk Insurance Extension Act, other coverage, no terrorism exclusion)? Please specify the limits that would apply to the terrorism coverage.
Item BD11.2. Unavailability of Insurance
The SAFETY Act provides that a Seller may not be required “to obtain liability insurance of more than the maximum amount of liability insurance reasonably available from private sources on the world market at prices and terms that will not unreasonably distort the sale price of Seller’s anti-terrorism technologies.” If you are unable to obtain appropriate insurance please provide information concerning your attempts to obtain insurance coverage for your Technology (e.g., written communications from insurance companies or brokers explaining why your Technology cannot be insured). If insurance is available for terrorism events but at rates which would distort the sales price of your Technology, document the prices of that insurance and provide the relevant information to support how it would affect the price of your Technology. You may wish to contact OSAI with questions concerning what information would be most helpful to provide in response to this item.
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.
Certain financial data may be utilized in the process for analyzing the appropriate amount of insurance coverage for your particular Technology. This is particularly true when questions arise as to whether insurance costs unduly distort the price of your Technology. Accordingly, you may be requested to provide certain financial data to OSAI as part of your application. That said, OSAI will not demand financial information when it is not necessary to a particular application, and will not disclose sensitive or proprietary information outside the application process.
Item BD12.1. It may be helpful to attach your latest financial statement. If you are a public company, your latest SEC 10-K annual report and SEC 10-Q quarterly report, together with any amendments thereto, should suffice. If your company is not publicly traded, 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 statements. OSAI will seek additional and more specific information only when necessary for a particular application.
In the process of answering the questions above, you might find it useful to attach additional documents in support of your answers. These items can be included in your application by using the “Additional Attachments” feature. When answering the items above, it is appropriate to refer to attachments by name and or number. Examples of common attachments might include, but are not limited to, the following: test reports demonstrating the effectiveness of the Technology, operating manuals, training manuals, project/program management plans, quality assurance plans, quality control plans, copies of company certifications, results from pilot studies, testimonials from customers, and warranties.
Declaration for Written Submissions
An authorized agent of the applicant must, in the presence of a Notary, sign and date this form before submitting it to OSAI. For electronic submissions or web submissions, follow the instructions provided at safetyact.gov.
The Secretary may issue Block Certifications at his discretion for anti-terrorism technologies that meet established performance standards or defined technical characteristics. Sellers of Technologies that are subject of a Block Certification may submit a streamlined application to be afforded the liability protection available under the SAFETY Act. Block Certification will be published on the AFETY Act Web site (http://www.safetyact.gov).
Each Block Certification may set forth particular terms and conditions that should be addressed in the accompanying application to be utilized in applying for SAFETY Act protection pursuant to a particular Block Certification.
(Block Certification form on following page)
SAFETY Act Block Certification Application
Application Type
BC1. Type of Application.
I am responding to an announced Block Certification. Reference: ________________ Date issued: ________; Technology Name____________
Resubmission of a Previous Application for an announced Block Certification.
Previous Application ID #: ____________________ Reference: ________________ Date issued: ________; Technology Name_________________
Registration Information
BC2. Registration Status (choose one):
I am updating or correcting previous registration information.
My previously provided registration information is still accurate:
BC3. Name of Seller: ____________________________________________________
BC4. Company Description. Provide an overview of your company, including a description of your business.
Block Certification
Respond to all items in this section in one attachment to this application. Additional supporting material can be attached as an appendix to your application.
BC5. 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 BC3.1 above, please identify each entity and the place in which it is organized.
BC6. Provide the earliest date of sale of the Technology for which you are requesting to SAFETY Act coverage.
BC7. Identify the Block Certification you are responding to by noting the name of the Block Certification and the date it was issued. Reference any special terms or conditions presented in the referenced Block Certification.
BC8 . Submit information demonstrating your Technology’s compliance with the technical specifications of the Block Certification.
BC9. Submit information demonstrating your Technology’s compliance with the terms and conditions of the referenced Block Certification.
BC10. Submit any other information concerning the Technology which may be helpful to the Department in consideration of this application.
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. |
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Prepared By: |
________________________________ |
Title (if applicable): ____________________ |
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Signature: |
______________________________________________ |
Date: ___/___/20__ |
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The signature of the Preparer must be notarized below: |
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State of: |
_______________ |
County of: |
__________________________ |
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Subscribed and sworn before me this |
_____ |
day of |
_____________________ |
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Notary Public: |
___________________________________________________ |
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My Commission Expires on: |
________________________________________ |
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Instructions for Completing Block Certification Application Form:
Application Type
Item BC1. Type of Application
If your application is in response to an announced Block Certification, check the appropriate box and follow the instructions set forth in the particular Block Certification announcement.
Registration Information
Item BC2. Registration Information
Please check the appropriate box relating to your registration status.
Item BC3. Name of Seller
Please provide the legal name of the Seller/applicant.
Item BC4. Company Description
The purpose of this item is to help the Department recognize potential conflicts of interest and to avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure.
Provide a brief description of your company. When describing your company, focus on identifying any affiliates associated with your Technology (e.g., parent companies, subsidiaries, joint venture partners, holding companies, etc.).
The purpose of the company description is to help the Department recognize potential conflicts of interest and avoid disclosing your application information to inappropriate evaluators. The Department is committed to protecting your sensitive business data from improper disclosure. Do not include any sensitive or proprietary information in this summary. If you wish to include information on substantially similar QATTs or provide information regarding who your major competitors are with respect to the subject Technology, you may do so.
Item BC5. Seller
In certain instances, multiple corporate entities may appropriately be identified as a Seller of the subject Technology. For instance, the Seller of the QATT could include a parent company as well as subsidiaries or other affiliates. Your response will be used to properly identify the Seller(s) of the QATT. If you would like multiple entities to be considered a Seller of the QATT, please clearly identify these firms and identify their respective place of incorporation.
This information will be used to specify the earliest date of sale of the QATT to which the Certification shall apply (note this date may be prior to the effective date of the Certification).
Item BC7. Identification of Block Certification
Please identify the Block Certification you are responding to by noting the name of the Block Certification and that date it was issued. Reference any special terms or conditions presented in the referenced Block Certification.
Item BC8. Compliance with Technical Merits
In order for the Under Secretary to extend SAFETY Act protections to your Technology, please provide sufficient information to demonstrate that your Technology complies the technical merits of the reference Block Certification. Please be specific.
Please demonstrate how your Technology complies with the terms and conditions stated in the referenced Block Certification. Please be specific and provide sufficient details.
Item BC10. Other Information
Please provide other information that may help the Department of Homeland Security as it considers your application. This may include information such as information demonstrating the Technology’s effectiveness, utility, and readiness for sale.
In the process of answering the questions above, you might find it useful to attach additional documents in support of your answers. These items can be included in your application by using the “Additional Attachments” feature. When answering the items above, it is appropriate to refer to attachments by name and or number. Examples of common attachments might include, but are not limited to, the following: test reports demonstrating the effectiveness of the Technology, operating manuals, training manuals, project/program management plans, quality assurance plans, quality control plans, copies of test reports demonstrating effectiveness, results from pilot studies, testimonials from customers, and warranties.
Declaration for Written Submissions
An authorized agent of the applicant must, in the presence of a Notary, sign and date this form before submitting it to OSAI. For electronic submissions or web submissions, follow the instructions provided at safetyact.gov.
Except as may be restricted by the terms and conditions of a particular Designation or Certification, a SAFETY Act Designation or Certification may apply to any other person, firm, or other entity to which the Seller licenses (exclusively or nonexclusively) the right to sell the Technology, in the same manner and to the same extent that such Designation applies to the original Seller. Sellers wishing to license the right to sell their Technology and its Designation or Certification should submit a “Notice of License of Qualified Anti-Terrorism Technology” within 30 days of the commencement of the license.
(Notice of License Form on following page)
Notice of License of Qualified Anti-Terrorism Technology
L1. Seller Name: ____________________________________________________
L2. QATT information
L2.1. QATT Name: _______________________________________________
L2.2. QATT Application ID Number: ________________________________
L3. Name of Licensee: _______________________________________________
L3.1. Licensee Place of Incorporation: _________________________________
L4. Method of License (choose one):
Exclusive
Non-Exclusive
L5. Date of Commencement of License: ____/____/20___
L6. Term of License: ________________________________________________
L7. Provide a description of the license agreement including an affirmation that SAFETY Act protections only attach to the Technology that is described in Exhibit A of the licensor’s letter of Designation or Certification, as applicable. Attach supporting information as necessary. Indicate that the transferee is cognizant of the requirement to meet the transferor’s insurance requirements and any other special conditions which might affect the deployment of the licensed technology.
L8. Provide information regarding the described licensing effect on the QATTs safety or efficacy, or risk(s) associated with its deployment.
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. |
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Prepared By: |
________________________________ |
Title (if applicable): ____________________ |
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Signature: |
______________________________________________ |
Date: ___/___/20__ |
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The signature of the Preparer must be notarized below: |
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State of: |
_______________ |
County of: |
__________________________ |
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Subscribed and sworn before me this |
_____ |
day of |
_____________________ |
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Notary Public: |
___________________________________________________ |
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My Commission Expires on: |
________________________________________ |
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Instructions for Completing Notice of License Form:
Enter the name of the current Seller of the QATT whose Designation you wish to license.
Item L2.1. QATT Name
Enter the name of the QATT as it appears in the Seller’s most recent correspondence with the OSAI.
Item L2.2. QATT Application Identification Number
Enter the Application Identification Number of the original Designation for this QATT.
Enter the registration name of the Licensee. This should be the company or business unit named used by the Licensee to register as a Seller. The recipient of the license must be registered with the OSAI before the notice of license can take place. See Chapter 5 of this kit for detailed instructions on how to register. Registration with the OSAI does not commit the registrant to any further actions.
Item L3.1. Place of Incorporation
Identify the place where the transferee is incorporated.
Check the box corresponding to the type of License you are performing. Check “Exclusive license” if the current Seller retains rights in the QATT and will not be transferring any of these same transferred rights to anyone other than the Licensee named in this form. Check “Non-exclusive license” if the current Seller retains rights and may transfer some or all of those rights to entities other than the Licensee named in this form.
Enter the date of the commencement of the license or the proposed date if that has not yet occurred. Use month/date/year format.
Enter term of license.
Summarize the nature and terms of the License agreement. Attach additional sheets if necessary.
Item L8. Effect
Please describe the effect the licensing will have on the QATT’s safety or efficacy and provide any available supporting information.
An authorized agent of the applicant must sign and date this form before submitting it to OSAI. For electronic submissions or web submissions, follow the instructions provided at safetyact.gov.
It is important and required that the Department be informed of any significant modifications that the Seller makes or intends to make to a Qualified Anti-Terrorism Technology (QATT). A significant modification is one that is outside the scope of a Designation or Certification. Immaterial or routine modifications that are within the scope of the Designation do not require notice. The SAFETY Act final rule modified the procedure for Sellers to notify the Department of modifications or proposed modifications to a QATT and for the Department to respond quickly to such notifications with appropriate instructions for the Seller. Immaterial or routine modifications that are within the scope of the Designation do not require notice. It is important, however, and required, that the Department be informed of any significant modifications that the Seller makes or intends to make to a QATT. A significant modification is one that is outside the scope of a Designation.
Whether notice to the Department is required for a change to a particular QATT will depend on the specific nature of the QATT and the terms of the Designation or Certification applicable to the QATT. If notice of a modification is required, review of the notice will also be undertaken in a reasonable time. If the Department does not take action in response to the notice, SAFETY Act coverage of the Technology as modified will be conclusively established. If the Department ultimately does not approve of the proposed changes, it will so notify the Seller and may discuss possible remedial action to address the Department’s concerns or take other appropriate action in the discretion of the Under Secretary, as provided in section 25.6(l) of the final rule. In no event will a Designation terminate automatically or retroactively under this provision. It is also important to recognize that the “significant modification” provisions may require notice by the Seller to the Department only when the modifications are made to a QATT by the Seller or are made to a QATT with the Seller’s knowledge and consent. The final rule does not require that a Seller notify the Department of changes to a QATT made post-sale by an end-user of the QATT, and any such change by an end-user cannot result in loss of SAFETY Act protection for the Seller or others protected by the Seller’s Designation or Certification. If notice of a modification is required, Sellers should submit to the Department a “Notice of Modification to Qualified Anti-Terrorism Technology.”
(Notice of Modification Form on following page)
Notice of Modification of Qualified Anti-Terrorism Technology
M1. Seller Name:
M2. Qualified Anti-Terrorism Technology (QATT) information
M2.1 QATT Name: ___________________________________________
M2.2 QATT Application ID Number: ____________________________
M3. Description of Modification: Attach a description of the modification the Seller has made or is intending to make to the QATT. The discussion should endeavor to frame the “before” and “after” attributes of the modifications to the QATT. Please also address why the Seller is making or intends to make such modification.
M4. Provide information regarding the described modification’s effect on the QATTs safety or efficacy, or risk(s) associated with its deployment.
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. |
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Prepared By: |
________________________________ |
Title (if applicable): ____________________ |
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Signature: |
______________________________________________ |
Date: ___/___/20__ |
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The signature of the Preparer must be notarized below: |
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State of: |
_______________ |
County of: |
__________________________ |
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Subscribed and sworn before me this |
_____ |
day of |
_____________________ |
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Notary Public: |
___________________________________________________ |
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My Commission Expires on: |
________________________________________ |
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Instructions for Completing Notice of Modification Form:
Item M1. Seller Name
Enter the name of the current Seller of the QATT whose Designation and, as applicable, Certification you wish to modify.
Item M2. QATT Information
Item M2.1. QATT Name
Enter the name of the QATT as it appears in the Seller’s most recent Certification of Designation or previous Modification Notice.
Item M2.2. QATT Application identification Number
Enter the Application Identification Number of the original Designation and, as applicable, Certification for this QATT.
Item M3. Description of Modification
Attach a document describing the proposed modifications in detail, along with any documentation or other information detailing the modification, as well as the need for or purpose underlying such modification.
Item M4. Effect
Please describe the effect the modification will have on the QATT’s safety or efficacy and provide any available supporting information.
An authorized agent of the applicant must sign and date this form before submitting it to OSAI. For electronic submissions or web submissions, follow the instructions provided at safetyact.gov.
Except as may be limited by its terms, any Designation and, as applicable, Certification may be transferred and assigned to any other person, firm, or other entity to which the Seller transfers and assigns the right, title, and interest in and to the Technology covered by the Designation and, as applicable, Certification, including the intellectual property rights therein. Transfers of a Designation and, as applicable, Certification will not be effective unless and until the Department is notified in writing through the “Application for Transfer of Designation” form. Upon the effectiveness of the transfer, the transferee will be deemed to be a Seller in the place and stead of the transferor for all purposes under the SAFETY Act.
(Application for Transfer Form on following page)
application for Transfer of SAFETY Act Designation and certification
Seller Information
T1. Name: __________________________________
T2. QATT Information
T2.1 QATT Name: _____________________________________________
T2.2
QATT Application Identification Number: ______________________
Transferee Information
T3. Name: ______________________________________________________
T3.1 Transferee’s place of incorporation: ____________________________
Description of Transfer
T4. Effective date of transfer: ____/____/20___
T5. Attach a description of the transfer agreement and supporting information as necessary.
T6. Insurance. Please provide information regarding the Transferee’s insurance coverage for the relevant QATT and whether the Transferee’s coverage satisfies the terms of insurance of the SAFETY Act Designation issued to the Transferor.
T7. Please provide information regarding the described transfer’s effect on the QATTs safety or efficacy, or risk(s) associated with its deployment.
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. |
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Prepared By: |
________________________________ |
Title (if applicable): ____________________ |
|
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Signature: |
______________________________________________ |
Date: ___/___/20__ |
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The signature of the Preparer must be notarized below: |
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State of: |
_______________ |
County of: |
__________________________ |
|||||||
Subscribed and sworn before me this |
_____ |
day of |
_____________________ |
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Notary Public: |
___________________________________________________ |
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My Commission Expires on: |
________________________________________ |
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Instructions for Completing Application Transfer Form:
Enter the name of the current Seller of the QATT you wish to transfer.
Item T2.1. QATT Name
Enter the name of the QATT as it appears in the Seller’s most recent correspondence with the OSAI.
Item T2.2. QATT Application Identification Number
Enter the Application Identification Number of the original Designation for this QATT.
Enter the registration name of the Transferee. This should be the company or business unit named used by the Transferee to register as a Seller. The recipient of the transfer must be registered with the OSAI before the transfer can take place. See Chapter 2 of this kit for detailed instructions on how to register. Registration with the OSAI does not commit the registrant to any further actions.
Item T3.1. Place of Incorporation
Identify the place where the transferee is incorporated.
Enter the date that the Transferee acquired the right to sell the QATT or the proposed date if that has not yet occurred. Use month/date/year format.
Summarize the nature and terms of the transfer agreement. What rights (if any) does the current Seller retain? What rights are transferred to the Transferee?
Item T6. Insurance
In order for SAFETY Act protections to transfer, the Transferee must meet any special conditions associated with the Designation and/or Certification. In addition, the Transferee must meet the obligation to maintain insurance as set forth in the SAFETY Act Designation issued to the Transferor.
Item T7. Effect
Please describe the effect the transfer will have on the QATT’s safety or efficacy and provide any available supporting information.
An authorized agent of the current Seller and an authorized agent of the Transferee must sign and date this form before submitting it to OSAI. For electronic submissions or web submissions, follow the instructions provided at safetyact.gov.
1 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.
2 Insurance premium: If possible, please indicate what percentage of the premium is allotted to coverage for Acts of Terrorism.
3 6 USC § 442(d)(2).
4 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.
5 Insurance premium: If possible, please indicate what percentage of the premium is allotted to coverage for Acts of Terrorism.
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.
| File Type | application/msword |
| File Title | SAFETY Act Application |
| Author | aneese |
| Last Modified By | sabrina.nelson |
| File Modified | 2006-08-09 |
| File Created | 2006-08-09 |