Cyber Liability Quote Request
General Information
Page 1 of 2
Company Name
*
Address
*
Street Address
Street Address Line 2
City
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Alabama
Alaska
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Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
Idaho
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Contact Name
*
First Name
Last Name
Title
Phone Number
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Area Code
Phone Number
E-mail
*
Website Address
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Underwriting / Rating Information
Page 2 of 2
Business Description
*
Number of years in operation
*
Please Select
Less than 3 years
More than 3 years
Gross Revenue (Est)
*
Breakdown of Employees By State
*
Does the applicant maintain computer security that includes a) firewall, b) anti-virus / anti-malware, c) automatic patch/vulnerability software updates, d) access controls that include passwords, at a minimum?
Yes
No
Has the applicant experienced any cyber related incident, fine or penalty in the past five (5) years that could have resulted in a claim under this policy?
Yes
No
Does applicant have any knowledge of an incident, event or circumstances that may result in a claim or loss under this policy?
Yes
No
How many customer records do you maintain? (estimate)
Optional eCrime: Does the applicant provide social engineering, CEO fraud/phishing and other types of fraudulent transfer request /scheme, annual training to all employees engaging and/or responsible for wire transfers?
Yes
No
Optional eCrime: Does the applicant have and use procedures requiring that all wire transfer requests and instructions be confirmed via a secondary verification source or path using a different method of communication than per the original request?
Yes
No
Premium credit option: A cyber liability insurance premium credit will apply subject to having each of the following cyber risk management items. Namely, does the applicant have and maintain i) administrative privileges restricted on all PCs/Workstations, ii) 2-Factor and/or MFA (multi-factor authentication) enabled and used on all cloud based email access and remote systems access (RDP); iii) administrative audit and mailbox audit logging enabled on Microsoft Exchange Servers (e.g. M365) and iv) data backup with processes and procedures to ensure the integrity of data backup at least every 90 days?
Yes
No
Does the company currently carry Cyber Liability Insurance coverage?
Yes
No
Currentt Insurer:
Current Limit of Liability:
Please Select
Less than 100,000
100,000
250,000
500,000
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
Other
Current Retention:
Please Select
2,500
5,000
7,500
10,000
15,000
20,000
25,000
50,000
More than 25,000
Other
Policy Expiration Date:
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Month
-
Day
Year
Date Picker Icon
Date of First Policy or Coverage:
-
Month
-
Day
Year
Date Picker Icon
Is Coverage Endorsed to a Commercial Policy?
Please Select
Yes
No
Submit
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