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CRYPTO SHIELD PRO+

DIGITAL ASSET AND FIAT CRIME INSURANCE APPLICATION

Complete all sections. Fields marked * are required. This application must be signed by a C-suite executive. All answers are legally material to the underwriting evaluation. Submit the completed form with the required attachments listed in Section 9.

The term "you/your" refers to all companies (including subsidiaries), insured persons, and additional insureds seeking coverage.

1 · General Information

Company Details

Country

Ownership Structure

Nature of Operations — Select All That Apply