Form DHS Form 10001 DHS Form 10001 Application for Transfer of Safety Act

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

APPLICATION FOR TRANSFER OF SAFETY ACT
DESIGNATION AND CERTIFICATION
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)

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 information for the purpose of contacting individuals
seeking liability protections on issues related to the application for SAFETY ACT Transfer of Safety Act Designation and Certification 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 10 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 10001 (10/06)

APPLICATION FOR TRANSFER OF SAFETY ACT DESIGNATION
AND CERTIFICATION
SELLER INFORMATION (TRANSFEROR)
T1. Company Name: __________________________________
T1.2. POC Name: _________________________________
T2. QATT Information
T2.1. QATT Name: __________________________________________
T2.2. QATT Application Identification Number: ____________________
TRANSFEREE INFORMATION
T3. Company Name: ____________________________________________
T3.1. POC Name: ___________________________________________
T3.2. Transferee’s place of incorporation:__________________________
T3.3. Company Description: Provide an overview of your company, description
of your business including number of employees and office location
associated with production of newly acquired QATT.
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. Please include the following information:
a. Primary named insured (as it appears on your insurance policy).
b. Additional named insured relevant to the Technology Sellers.
c. Type of policy(ies) (e.g., Comprehensive General Liability, Errors and

Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.)

DHS Form 10001 (10/06)

d. Policy Dates. (Start and end)
e. Insurer.
f. Per-occurrence limits.1
g. Aggregate limits.
h. Annual Premium(s).2
i.

Deductible(s) or Self-insured retentions.

j.

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 sub-paragraph “c” above).

k. Please describe the type and limits of terrorism coverage for this policy.

Please elaborate on the applicability of the policies identified in subparagraph “c” to address the foreseeable risks associated with the
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) covers 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.

T7. Revenue.
T7.1 Revenue Projection.
In order for us to determine the amount of insurance that would not
unreasonably distort the sales price of your Technology, we need you to
provide us with three (3)-year projected (prospective) revenue estimates for
your Technology - all assuming that your Technology is approved under the
SAFETY Act. The three-year period should include your current fiscal year,
if incomplete, and two subsequent years.

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.
DHS Form 10001 (10/06)

If you do not have current year sales for your Technology, please provide us
with three (3)-year projected revenue data.
The revenue data needs only to pertain to your Technology and the numbers
need only be summarized data (that is, we do not require the revenue
sources to be itemized). The revenue data should be matched with
summarized cost data (e.g., cost of goods sold); as with the revenue data, we
do not require breakdown of data by cost centers.
T7.2 Financial Data
Certain financial information regarding your company and
projected/prospective Technology revenue may be particularly relevant to
the application process. This is particularly true when questions arise as to
whether insurance costs for specified coverage limits unduly distort the price
of your Technology. We may request additional financial information from
the Applicant if necessary.
T8. Please provide information regarding the described transfer’s effect on the
QATT’s safety or efficacy, or risk(s) associated with its deployment.
If POCs are provided as sources of information or testimonials, check below to
indicate that you have contacted them and that they are expecting to hear from
DHS related to your Technology. Also, indicate below what information we should
expect from each POC.
The POCs are expecting contact from DHS. The information the POC can
provide or verify is:
____________________________________________________________
____________________________________________________________
____________________________________________________________

DHS Form 10001 (10/06)

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__

Company Name: _________________________________________

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 10001 (10/06)

County of: __________________________

________________________________________

Instructions for Completing Application Transfer Form:
Seller Information
Item T1. Seller Name
Enter the name of the current Seller of the QATT you wish to transfer.

Item T2. QATT Information
Item T2.1. QATT Name
Enter the name of the QATT as it appears in the Seller’s most recent correspondence
with the Office of SAFETY Act Implementation (OSAI).
Item T2.2. QATT Application Identification Number
Enter the Application Identification Number of the original Designation for this
QATT.

Transferee Information
Item T3. Name
Enter the registration name of the Transferee. This should be the company or
business unit name used by the Transferee to register as a Seller. The recipient of the
transfer must be registered with OSAI before the transfer can take place. See
Chapter 2 of this kit for detailed instructions on how to register. Registration with
OSAI does not commit the registrant to any further actions.
Item T3.2. Place of Incorporation
Identify the place where the transferee is incorporated.
Item T3.3. Company Description
Provide an overview of your company, description of your business including
number of employees and office location associated with production of newly
acquired QATT.

Description of Transfer
Item T4. Effective Date of Transfer of Rights
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.

Item T5. Brief Description
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?
DHS Form 10001 (10/06)

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.
For item 6a., 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 6k., 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 T7. Revenue
Item T7.1. Revenue Projection
Please provide us with three (3)-year projected (prospective) revenue data for your
Technology. The three-year period should include the current fiscal year, if
incomplete, and two subsequent years (best estimate). If you do not have current
year sales data for your Technology, please provide us with best estimate projections
for the three years following the launch of the Technology. The SAFETY Act
requires Sellers of anti-terrorism technologies to obtain liability insurance of such
types and in such amounts to satisfy otherwise compensable third-party claims arising
out of, relating to, or resulting from an act of terrorism when a Technology has been
deployed in defense against, response to, or recovery from an act of terrorism.
Technology revenue projections are of particular relevance in the application
process. This is true when questions arise as to whether insurance costs unduly
distort the price of your Technology.
Item T7.2. Financial Data
Certain financial data may be used 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 asked to provide certain financial data to
OSAI as part of your application. If this is the case, 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.

DHS Form 10001 (10/06)

Item T8. Effect
Please describe the effect the transfer will have on the QATT’s safety or efficacy and
provide any available supporting information.
If POCs are provided as sources of information or testimonials, please indicate that
you have contacted them and that they are expecting to hear from DHS related to
your Technology. Also, indicate what information we should expect from each POC.

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

DHS Form 10001 (10/06)