Form DHS Form 10002 DHS Form 10002 Notice of Modification

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

NOTICE OF MODIFICATION OF QUALIFIED ANTITERRORISM TECHNOLOGY
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. 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. 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. 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 at 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)

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: When any individual, business entities or other entities seeking to make significant modifications to the Qualified
Anti-Terrorism Technology fill out the SAFETY Act Notice of Modification of Qualified Anti-Terrorism Technology, DHS collects telephone
numbers, addresses, and other identifying information for the purpose of contacting individuals seeking liability protections on modifications related to
the SAFETY ACT 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 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 10002 (10/06)

NOTICE OF MODIFICATION OF QUALIFIED ANTI-TERRORISM
TECHNOLOGY
M1. Seller Name: __________________________________________________
M1.1. 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 anti-terrorism
technologies. [For example, if you apply for Designation and Certification and
receive Designation, your Technology will be listed under Designated
Technologies. Or, if you are granted DT&E Designation, regardless of which
protection you applied for, you will be so listed on the Web site. 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 this Technology listed on the public Web site under the
appropriate classification.
I do not wish to have this Technology listed on the public Web site under the
appropriate classification.
M2. Qualified Anti-Terrorism Technology (QATT) information
M2.1. QATT Name: ___________________________________________
M2.2. QATT Application ID Number: ____________________________
M3. Modification Type
M3.1 Technical Modification
a. 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.
b. Provide any information on the impact that this Modification would have
on the projected revenue of your QATT.
c. If your Modification includes the addition of Sellers, confirm that your
current insurance coverage extends to these Sellers or provide information
DHS Form 10002 (10/06)

demonstrating that additional Sellers maintain the required insurance to
respond to SAFETY Act claims.
M3.2 Insurance Petition
Request for Insurance revision: If you are petitioning for a revision to the
insurance requirement contained in your Certificate of Designation pursuant to
Section 25.5(g) of the SAFETY Act Regulations, please provide a basis for you
petition, to include but not limited to, QATT market conditions, financial status
of your firm, insurance premia, and revisions to your insurance policy(ies) by the
carrier.
a. Any petition to reduce the amount of insurance required by your Certificate
of SAFETY Act Designation, that is available to satisfy otherwise
compensable third-party claims arising out of, relating to, or resulting from
an act of terrorism where your QATT deployed in defense against,
response to, or recovery from such act should include all of the following
information related to your proposed new insurance liability limit:
i.

Primary named insured (as it appears on your insurance policy).

ii. Additional named insured relevant to the QATT Sellers.
iii. Type of policy(ies) (e.g., Comprehensive General Liability, Errors and

Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.)
iv. Policy Dates. (Start and end)
v. Insurer.
vi. Per-occurrence limits.1
vii. Aggregate limits.
viii. Annual Premium(s).2
ix. Deductible(s) or Self-insured retentions.
x. 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).
xi. Please describe the type and limits of terrorism coverage for this

policy. Please elaborate on the applicability of the policies identified

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 10002 (10/06)

in sub-paragraph “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.
xii. 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 nonSAFETY 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.
b. Insurance Point of Contact: 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 QATT. Also, indicate below what information we should expect from
each POC.
c. 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.
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.
M4. Provide information regarding the described modification’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 10002 (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__

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 10002 (10/06)

County of: __________________________

________________________________________

Instructions for Completing Notice of Modification Form:
Seller Information
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 M3.1 Technical 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.
Please also address the impact any Modification will have on QATT sales. If a
change in proposed to include additional Sellers, please verify that your current
insurance coverage applies to these Sellers.

Item M3.2 Insurance Petition
Your petition should include a basis or explanation of why your required insurance
should be revised. You must provide the details requested in Item M3.2 (a-l); include
any relevant documentation to support your petition (e.g., letters from carriers or
insurance brokers).

Item M4. Effect
If you are filing an insurance petition, no response is required to this question.
Please describe the effect the modification will have on the QATT’s safety or efficacy
and provide any available supporting information.
This should include any test and evaluation data, relevant certifications, or the like. If
you are extending your QATT to a new sector, describe any changes to the QATT
and tests conduct to verify that your QATT will be effective in a new location. If you

DHS Form 10002 (10/06)

are adding a product line, please describe how this new product line compares to
product lines currently included as part of your QATT.
Also, if associated technical documentation, or policies and procedures, are impacted
by changes in your QATT, provide these updated documents.
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.

Declaration
An authorized agent of the Applicant 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 10002 (10/06)