Form DHS Form 10057 DHS Form 10057 Application for Renewal

OMB Control No. 1640-0001
Expires: 03/31/2013

APPLICATION FOR RENEWAL OF SAFETY ACT
PROTECTIONS OF A QUALIFIED ANTI-TERRORISM
TECHNOLOGY
The purpose of completing an Application for Renewal of SAFETY Act Protections is for
you, the Seller of the approved Qualified Anti-Terrorism Technology, to ensure that your
QATT performed as previously described throughout the lifespan of your previous
Designation or Certification and that it will continue to perform in the future. To ensure
your QATT does not encounter a lapse in SAFETY Act coverage, it is recommended that
you file a Renewal application at least 6 months prior to expiration of your current award.
(Application for Renewal Form on following page)

Privacy Act Notice: DHS Authority to Collect This Information: 6 U.S.C. §§ 441–444 (the “SAFETY Act”) and 6 C.F.R. Part 25, 71 Fed. Reg.
33147, 33159. Principal Purposes: DHS collects telephone numbers, addresses, and financial and insurance information for the purpose of
contacting individuals seeking liability protections on issues related to the application for renewal of SAFETY ACT protections of a qualified antiterrorism technology application process. Routine Uses and Sharing: In general, DHS will not use this information for any purpose other than
DHS personnel contacting the individual. However, DHS may release this information of an individual on a case-by-case basis as described in the S&T
SAFETY Act System of Records Notice (SORN), which can be found at: www.dhs.gov/privacy. Disclosure: Submission of this information is
voluntary and an individual may opt not to provide the requested information or to provide only some of the information DHS requests. If an
individual chooses to opt not to provide some or all of the requested information, DHS may not be able to process the individual’s request.
PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this
information collection unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 16400001 and this form will expire on 03/31/2013. The estimated average time to complete this form is 50 hours per respondent. If you have any
comments regarding the burden estimate you can write to Department of Homeland Security, Science and Technology Directorate, Washington, DC
20528.
DHS Form 10057 (6/09)

Application for Renewal
Please address each question below, answering as fully as possible and include
supporting documentation; please label this documentation with the appropriate
application number.
RE1. Seller Name: _______________________________________________________
RE1.1. Public Web site Listing
If your Technology is awarded SAFETY Act coverage, you have the
opportunity to be listed on the SAFETY Act Web site as a Designated Seller of
a Qualified Anti-Terrorism Technology (QATT). Note: By statute, all Certified
Technologies will be displayed in the Approved Products List for Homeland
Security on the Web site.
I wish to have my QATT listed on the public Web site under the appropriate
classification.
I do not wish to have my QATT listed on the public Web site under the
appropriate classification.
RE2. Qualified Anti-Terrorism Technology (QATT) Information.
RE2.1. QATT Name: __________________________________________________
RE2.2. QATT Application ID Number: ____________________________________
RE3. Point of Contact (POC) Information
RE3.1. Financial/Insurance POC:

Name: _______________________________________________________
Address: _____________________________________________________
Telephone Number: ____________________________________________
Fax Number: __________________________________________________
E-mail address: ________________________________________________

RE3.2. Technical POC:

Name: _______________________________________________________
Address: _____________________________________________________
Telephone Number: ____________________________________________
Fax Number: __________________________________________________
E-mail address: ________________________________________________

RE4. Technical Specifications

DHS Form 10057 (6/09)

RE4.1. Describe what (if anything) has changed about the QATT since SAFETY Act
protections were awarded. If you have made changes to your technology and
elected not to file a Modification, provide information regarding this decision.
a. Please review “Exhibit A” of your award or most recent modification
and ensure that all elements of your QATT are present. Propose any
changes as necessary; however, it will be important to justify additions
with information supporting the effectiveness of your QATT.
RE4.2. Confirm that your QATT continues to conform to the technical specifications
laid out for it in your successful SAFETY Act application and explain how you
know that these specifications continue to be met.
a. Provide information about quality control/assurance plans, especially if
your plan has been updated. If your plan has not been updated, please
describe why.
b. Provide information about updates to any policies and procedures
supporting your QATT. If no changes have been made, please indicate
why.
RE5. Performance
RE5.1. Provide an up-to-date deployment history of your QATT since it received
SAFETY Act protections, including deployment sites.
a. How many people do you have employed who deal with providing the
QATT? If you produce a product, how many help to manufacture this
product? If you provide a service, how many individuals are involved in
its deployment?
b. If you produce a product, in what city/state have you been
manufacturing the QATT?
RE5.2. Provide any information of which you are aware on the actual performance of
your QATT during the term of your most recent Designation or Certification.
This information should include reports from either test events or actual
deployments in which the QATT was used after SAFETY Act protections were
awarded. Include any new evidence of effectiveness of your Technology that is
available.
a. If you do not maintain records of field performance, please describe
why.
b. If a service provider, please provide most recent internal or external
audits. If no such quality audits are available, describe why.
c. As applicable, provide information on repair or reliability rates.
RE5.3. Provide evidence of continued QATT capability and efficacy. Describe how
you maintained currency of your QATT, given technology changes and current
and anticipated terrorist threats. If you are aware of any relevant and new
DHS Form 10057 (6/09)

technical literature and reports in the trade press and general circulation media,
include this information.
a. If you are a service provider, provide up to date information on
professional certifications or licensures, as applicable, as well as a
record of training for practitioner.
b. For all technologies, if you maintain any certifications or licensures
(ISO, FDA approval, etc.), please indicate whether all certifications or
licensures are current.
c. If you have allowed a certification or license to lapse, please describe
why.
RE5.4. If there have been instances since your last award decision in which your QATT
did not perform as projected in your successful application for SAFETY Act
protection, please explain how you know that your Technology would still be
effective against Acts of Terrorism.
RE5.5. If you have experienced unexpected difficulties in the deployment of your
QATT, especially impacting effectiveness, during the lifetime of your current
Designation, identify these difficulties.
a. Please indicate how any difficulties were resolved (sub-component
change, additional processes or procedures, process changes, etc.)
b. Please describe the impact of resolution or mitigation steps on the
effectiveness of your QATT.
RE5.6. For some QATTs, concerns may arise whether performance will degrade with
the passage of time after manufacture or deployment. Accordingly, please:
a. Discuss any decays experienced in performance of your QATT since
manufacture or deployment.
b. Identify any steps you have taken to control these decays and/or
inform buyers of your QATT of them.
c. If available, provide POCs that have experience with your QATT and
can provide information regarding its deployment and operation.
RE6. Safety
RE6.1. Provide information related to the safety of your QATT, for both its users and
those who may come in contact with it. This could include post deployment
safety and hazard reports, descriptions of safety incidents during the term of
your Designation, and similar data. Confirm that your Technology has
continued to be safe for use since receiving SAFETY Act Protections.
RE6.2. If there have been safety related incidents with your QATT since your last
award decision, please explain how you know that your technology remains safe
for use as intended.
DHS Form 10057 (6/09)

a. Have any workers compensation claims been filed relating to your
QATT?
RE7. Insurance Information
RE7.1. Did you notify your insurance carrier and/or insurance broker about the
enhancements, alterations, or other significant changes to your QATT described
above? If not, why not?
RE7.2. Provide the information indicated below for any and all current liability
insurance policies available to satisfy other otherwise compensable third-party
claims arising out of, relating to, or resulting from and Act of Terrorism were
your Technology deployed in defense against, response to, or recovery from
such an act:
a. Primary named insured (as it appears on your insurance policy)
b. Additional named insured relevant to the technology Sellers.
c. Type of Policy (Indicate all policies that apply, e.g. Comprehensive
General Liability, Errors and Omissions, Aviation, Product Liability,
SAFETY Act Liability, etc.)
d. Policy dates (start and end).
e. Insurer.
f. Per-occurrence limits. (Indicate whether each policy has a different
limit or deductible/self-insured retention for terrorist acts from the
general policy limit and, if so, provide both.)
g. Aggregate limits.
h. Annual Premium(s). (Indicate what percentage of the premium is
allotted to coverage for Acts of Terrorism. Consult with your insurance
carrier or broker if you do not have this information.)
i. Deductible(s) or self-insured retentions.
j. Exclusions. (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 6b.iii.
above.)
k. Types and limits of terrorism coverage for this policy. (Elaborate on
the applicability of the policies identified in 6b.iii. above to address the
foreseeable risks associated with the deployment of the Technology,
including risks arising from the deployment of the Technology in
advance of or in response to an Act of Terrorism. Please also indicate
whether the identified policies provide coverage under the Terrorism
Risk Insurance Act of 2002, as amended, or under other insurance
provisions or endorsements.)
l. Dedicated or shared limit. (describe whether the relevant polices cover
SAFETY Act claims and whether they have a dedicated limit that
applies to SAFETY Act claims only or a shared limit (i.e., share with
DHS Form 10057 (6/09)

non-SAFETY Act claims). Also indicate whether you have received a
written interpretation letter from the insurance carrier or broker
indicating whether the policies cover SAFETY Act claims; if so, please
provide a copy of such a document.
RE7.3. Supply the same insurance information requested in 7b above, but for the
previous two years. If your insurance has not changed, please indicate this;
however, you must include premium information as requested in 7b for the
previous two years.
RE8. Financial Information
RE8.1. Financial Information
a. Provide actual QATT revenue for the past three fiscal or calendar
years.
b. Provide QATT revenue projections for the next three years.
c. Provide the prior year’s actual or the current year’s projected income
statement.
RE8.2. List and briefly describe lawsuits filed involving your QATT.
RE8.3. List and briefly describe non-adjudicated settlements involving your QATT.
RE8.4. Provide financial data on the deployment by calendar year of your QATT since
you received SAFETY Act protections.
RE9. Summary of QATT qualifications
Include any other information the Department should consider in evaluating your
application for renewa.

DHS Form 10057 (6/09)

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

Title (if applicable): _______________

Signature: ______________________________________________ Date: ___/___/20__

The signature of the Preparer must be notarized below:
State of:

_______________

Subscribed and sworn before me this

Notary Public:

_____

day of

_____________________

___________________________________________________

My Commission Expires on:

DHS Form 10057 (6/09)

County of: __________________________

________________________________________

Instructions for Completing Application for Renewal:
Application Type
RE 1. Seller Name

Enter your Seller name as listed on your registration form.

RE 1.1. Public Web site Listing

Select whether or not you would like the Department to list your company and associated
Technology on the public SAFETY Act Web site page as a Designated Seller of antiterrorism technologies.

Qualified Anti-Terrorism Technology (QATT) Information
RE 2.1. QATT Name

Enter the name of your Technology. Use the name that appears on your most recent
Certificate of SAFETY Act Designation or Modification Notice.

RE 2.2. QATT Application ID Number

Enter a unique identifier for your renewal application.

RE 3. Description of Renewal
Point of Contact (POC) Information

This information will be pulled in from your user account Primary POC and Secondary POC
and displayed in the Seller Information section of your application. If the information is no
longer current, please update your user account information by following the instructions on
the Seller Information page.

RE 4. Technical Specifications
RE 4.1. The purpose of this item is to help the Department understand what, if anything

has changed with your QATT since the most recent Designation or Modification, and allow
you to review “Exhibit A.” Recall that Exhibit A is the legal definition of your QATT for
the purposes of the SAFETY Act.
.
RE 4.2. It is important to describe to the Department any changes in your quality
control/quality assurance plans. This allows applies to any policies and procedures included
in your QATT. This includes such things as changes to operator or practitioner training
policies or schedules, deployment policies (such as installation plans or management plans),
manuals, warranties, and other relevant technical documentation. Please provide copies of
the most recent versions of these items and indicate what items underwent revision.

RE 5. Performance
RE5.1. Provide up to date deployment information. For example, if you are the maker of a

sensor, how many units have been sold since receiving SAFETY Act protections? Where

DHS Form 10057 (6/09)

are these sensors located? If you provide a service, how many locations do you service?
What types of locations do your service? An up to date contract list might be appropriate in
answering this question.

RE 5.2. In this item, the Department is requesting information that describes how your

QATT has performed since your initial Award. Provide any information of which you are
aware on the actual performance of your QATT during the term of your most recent
Designation or Certification. This information could include reports from either test events
or actual deployments in which the QATT was used after SAFETY Act protections were
awarded. Include any new evidence of effectiveness of your Technology that is available. For
products, this should include maintenance and reliability information. For services, this
should include the results of internal and external audits or performance reviews. If you
have elected to not collect information about your success in the field please indicate why.

RE 5.3. Describe how you maintained currency of your QATT, given technology changes
and the evolving nature of threats. If you are aware of any relevant and new technical
literature and reports in the trade press and general circulation media, include this.

RE 5.4. If there have been instances since your last award decision in which your QATT

did not perform as projected in your successful application for SAFETY Act protections,
please explain how you know that your Technology would still be effective against Acts of
Terrorism.

RE 5.5. Often, unexpected challenges may arise during deployment that require changes to
technical specifications or describe any challenges encountered during deployment, any
changes made to counter any difficulties, and any impact that these changes have on the
effectiveness of your QATT.

RE 5.6. For some QATTs, concerns may arise whether performance will degrade with the

passage of time after manufacture or deployment. Accordingly, please: (1) provide evidence
of which you are aware of on likely decays in performance of your QATT since manufacture
or deployment; and (2) identify any steps you have taken to control these decays and/or
inform buyers of your QATT of them. If available, provide POCs that have experience with
your QATT and can provide information regarding its deployment and operation. If you
specify POCs, notify these individuals in advance that a representative from the Office of
SAFETY Act Implementation will be contacting them about your QATT.

RE 6. Safety

The purpose of this item is to help the Department verify that your QATT is safe for use as
intended. Provide available information related to the safety of your Technology, for both its
uses and those who many come in contact with it. This could include post deployment safety
and hazard reports, descriptions of safety incidents during the term of your Designation, and
similar data. If there have been safety related incidents with your QATT since your last

DHS Form 10057 (6/09)

award decision, please explain how you know that your Technology remains safe for use as
intended.

RE 7. Insurance Information
RE 7.1. Did you notify your insurance carrier and/or insurance broker about the

enhancements, alterations, or other significant changes to your QATT described above? If
not, why not?

RE 7.2. Provide the information indicated below for any and all current liability insurance

policies available to satisfy other otherwise compensable third-party claims arising out of,
relating to, or resulting from an Act of Terrorism were your Technology deployed in defense
against, response to, or recovery from such an act:
a. Primary named insured (as it appears on your insurance policy)
b. Additional named insured relevant to the technology Sellers.
c. Type of Policy (Indicate all policies that apply, e.g. Comprehensive General
Liability, Errors and Omissions, Aviation, Product Liability, SAFETY Act
Liability, etc.)
d. Policy dates (start and end).
e. Insurer.
f. Per-occurrence limits. (Indicate whether each policy has a different limit or
deductible/self-insured retention for terrorist acts from the general policy limit
and, if so, provide both.)
g. Aggregate limits.
h. Annual Premium(s). (Indicate what percentage of the premium is allotted to
coverage for Acts of Terrorism. Consult with your insurance carrier or broker if
you do not have this information.)
i. Deductible(s) or self-insured retentions.
j. Exclusions. (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 6b.iii. above.)
k. Types and limits of terrorism coverage for this policy. (Elaborate on the
applicability of the policies identified in 6b.iii. above to address the foreseeable
risks associated with the deployment of the Technology, including risks arising
from the deployment of the Technology in advance of or in response to an Act of
Terrorism. Please also indicate whether the identified policies provide coverage
under the Terrorism Risk Insurance Act of 2002, as amended, or under other
insurance provisions or endorsements.)
l. Dedicated or shared limit. (describe whether the relevant polices cover SAFETY
Act claims and whether they have a dedicated limit that applies to SAFETY Act
claims only or a shared limit (i.e., share with non-SAFETY Act claims). Also
indicate whether you have received a written interpretation letter from the
insurance carrier or broker indicating whether the policies cover SAFETY Act
claims; if so, please provide a copy of such a document.)

DHS Form 10057 (6/09)

RE 7.3. Supply the same insurance information requested in 6b above, but for the previous
two years. If your insurance has not changed, please indicate this; however, you must include
premium information as requested in 6b for the previous two years.
RE 8. Financial Information
RE 8.1. Financial Information

a. Provide actual QATT revenue for the past three fiscal or calendar years.
b. Also provide QATT revenue projections for the next three years.
c. Provide the prior year’s actual or the current year’s projected income statement.
RE 8.2. List and briefly describe lawsuits files involving your QATT.

RE 8.3. List and briefly describe non-adjudicated settlements involving your QATT.
RE 8.4. Provide data on the deployment by calendar year of the QATT since you received
SAFETY Act protections.

RE 9. Summary of QATT Qualifications

Include any other information the Department should consider in evaluating your
application for renewal.

Additional Attachments

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 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, 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 or Web submissions, follow the
instructions provided at safetyact.gov.

DHS Form 10057 (6/09)