DHS Form 10057 APPLICATION FOR RENEWAL OF SAFETY ACT PROTECTIONS OF A Q

OMB Control No. 1640-0001

Expires: 03/31/2016

Department of Homeland Security

Science and Technology Directorate

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 anti- terrorism 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 1640- 0001 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

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.

1. 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.

1. Provide information about quality control/assurance plans, especially if your plan has been updated. If your plan has not been updated, please describe why.

2. 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.

1. 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?

2. 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.

1. If you do not maintain records of field performance, please describe why.

2. If a service provider, please provide most recent internal or external audits. If no such quality audits are available, describe why.

3. 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

technical literature and reports in the trade press and general circulation media, include this information.

1. 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.

2. For all technologies, if you maintain any certifications or licensures (ISO, FDA approval, etc.), please indicate whether all certifications or licensures are current.

3. 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.

1. Please indicate how any difficulties were resolved (sub-component change, additional processes or procedures, process changes, etc.)

2. 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:

1. Discuss any decays experienced in performance of your QATT since manufacture or deployment.

2. Identify any steps you have taken to control these decays and/or inform buyers of your QATT of them.

3. 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.

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:

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

2. Additional named insured relevant to the technology Sellers.

3. Type of Policy (Indicate all policies that apply, e.g. Comprehensive General Liability, Errors and Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.)

4. Policy dates (start and end).

5. Insurer.

6. 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.)

7. Aggregate limits.

8. 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.)

9. Deductible(s) or self-insured retentions.

10. 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.)

11. 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.)

12. 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.

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

1. Provide actual QATT revenue for the past three fiscal or calendar years.

2. Provide QATT revenue projections for the next three years.

3. 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.

DECLARATION FOR WRITTEN SUBMISSIONS

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 anti- terrorism 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.

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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

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

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:

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

2. Additional named insured relevant to the technology Sellers.

3. Type of Policy (Indicate all policies that apply, e.g. Comprehensive General Liability, Errors and Omissions, Aviation, Product Liability, SAFETY Act Liability, etc.)

4. Policy dates (start and end).

5. Insurer.

6. 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.)

7. Aggregate limits.

8. 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.)

9. Deductible(s) or self-insured retentions.

10. 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.)

11. 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.)

12. 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.)

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

1. Provide actual QATT revenue for the past three fiscal or calendar years.

2. Also provide QATT revenue projections for the next three years.

3. 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.