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CYBER LIABILITY INSURANCE QUOTE FORM
Ten Seventy Pty Ltd t/a Reef Insurance Brokers is an Authorised Representative (AR # 1285127) of United Insurance Group (UIG) AFS Number 327131
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1
YOUR HAVE A DUTY OF DISCLOSURE OBLIGATION
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Ok, so before we start we need to tell you some things... Yes, it's boring, but it’s important and we need to do this - it only takes a minute. YOUR DUTY OF DISCLOSURE Before you enter into an insurance contract, you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, that may affect the insurer’s decision to insure you and on what terms. NOTE: You have this duty until the insurer agrees to insure you. You have the same duty before you renew, extend, vary, or reinstate an insurance contract. You do not need to tell the insurer anything that: • reduces the risk they insure you for; or • is common knowledge; or • the insurer knows, or should know; or • the insurer waives your duty to tell them about. IF YOU DO NOT TELL THE INSURER SOMETHING If you do not tell the insurer anything you are required to, they may cancel your contract, or reduce the amount they will pay you if you make a claim, or both. If your failure to tell the insurer is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed. DUTY TO NOT MAKE A MISREPRESENTATION NOTE: if you are applying for a new consumer insurance contract, renewing a consumer insurance contract or varying an existing consumer insurance contract, which is an insurance policy obtained wholly or predominately in relation to personal, domestic or household insurance purposes, you must answer the specific questions asked by the insurer truthfully and accurately. In answering those questions, you must tell the insurer all information that’s known to you and that a reasonable person would be expected to provide in answer to the questions. APPLYING FOR A NEW CONSUMER INSURANCE CONTRACT OR VARYING AN EXISTING CONSUMER INSURANCE CONTRACT. • You have a duty under the Insurance Contracts Act 1984 (ICA) to take reasonable care not to make a misrepresentation to the insurer (your duty). • Your duty applies only in respect of a policy that is a consumer insurance contract, which is a term defined in the ICA. • Your duty applies before you enter into the policy, and also before you renew, extend, vary, or reinstate the policy. • Before you do any of these things, you may be required to answer questions and the insurer will use the answers you provide in deciding whether to insure you, and anyone else to be insured under the policy, and on what terms. To ensure you meet your duty, your answers to the questions must be truthful, accurate and complete. • If you fail to meet your duty, the insurer may be able to cancel your contract, or reduce the amount it will pay if you make a claim, or both. • If your failure is fraudulent, the insurer may be able to refuse to pay a claim and treat the contract as if it never existed.
This Insurance is issued on a CLAIMS MADE and NOTIFIED basis.
This means that these covers only respond to: (1) Claims first made against you during the insurance period and notified to the Insurer during that insurance period, providing that you were not aware at any time prior to the policy inception of circumstances which would have put a reasonable person in your position on notice that a Claim may be made against you; and (2) Claims notified pursuant to Section 40, sub-section 3 of the Insurance Contracts Act 1984 (Cth.), which states: “Where the Insured gave notice in writing to the Insurer of facts that might give rise to a Claim against the Insured as soon as was reasonably practicable after the Insured became aware of those facts but before the insurance cover provided by the Contract expired, the Insurer is not relieved of liability under the contract in respect of the Claim, when made, by reason only that it was made after the expiration of the period of insurance cover provided by the Contract”.
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2
Policy Start Date:
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We can't back date a start date, so if you are not sure - choose today. We can sort this out later.
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Date
DD
MM
YYYY
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3
Company Name:
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if required
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4
Trading Name:
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5
ABN:
ABN Look Up
if required
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6
Please tell us your Name?
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First Name
Last Name
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7
What is your Business Address?
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We need a street address please - your postal address is the next question. If you are a mobile business please tell us your home base address.
Street Address
Street Address
City
State
Post Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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8
Do you have a different Postal Address?
If you don't have a postal address - leave this blank
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9
What is your Phone Number?
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Area Code
Phone Number
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10
Email:
*
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so we can email you your quote.
example@example.com
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11
Description of Business Activities:
*
This field is required.
Please tell us what you do - this questions applies to any subsidiaries you have too?
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12
You're doing great. How many employees do you have?
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An approximate head count if fine.
Head count - not FTE
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13
You're doing great. How much cover do you want?
This is the policy limit - remember it has to cover the worst case scenario.
$500,000
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
Other
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14
What is your estimated Annual Turnover:
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This is your income before Wages, Expenses and Tax please for the coming full 12 months.
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15
Do you secure remote access into your network and data (SSL, IPSec, SSH etc)?
*
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SSL = Secure Sockets Layer, IPSec = (IP security) protocols that ensure the integrity, confidentiality and authentication of data communications over an IP network, SSH = Secure Shell - a method of secure remote login from one computer to another. .
Yes
No
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16
Do you use commercially licenced firewalls and antivirus?
*
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E.g.: Norton or Mcfee ... not the open source software you can down load for free.
Yes
No
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17
Do you enforce a policy of auditing and managing computers and user accounts including password changes every 6-12 weeks?
*
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Yes
No
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18
Are all your mobile devices password protected?
*
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This includes mobiles, laptops, tables and memory / USB sticks.
Yes
No
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19
Does your disaster recovery plan or business continuity plan take into account Cyber perils?
*
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Yes
No
We don't have either of these
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20
How long would your business be impacted by a Cyber peril such as a hack or ransom of data?
*
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12 hours
24 Hours
48 hours
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21
Do you back up critical data at least once a week?
*
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Yes
No
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22
Do you outsource any critical systems or applications to third parties?
*
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Yes
No
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23
Ok, please tell us what systems are outsources and to whom?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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24
Do you want cover for Social Engineering, Phishing or Cyber Fraud?
*
This field is required.
FYI - these are the most common types of Cyber events that are claimed on insurance, so lets add them in a get a quote...Yes?
Yes please
No thanks
I don't know...quote me please?
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25
Are all requests to alter supplier or customer details - including bank details independently verified with a known contact (of the customer or supplier)?
*
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Yes
No
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26
Do you ensure that at least 2 members of staff authorise any transfer of electronic funds, issuing of cheques and disbursement of fund or investments over $2,000?
*
This field is required.
Yes
No
It's just me - I am a sole operator.
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27
Have you ever been investigated in respect of personally identifiable information, including payment card information or your privacy practices?
*
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Yes
No
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28
Have you been asked to supply any regulator or similar regulatory body with information relating to personally identifiable information or your privacy practices?
*
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Yes
No
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29
Have you ever been asked to sign a consent order or equivalent in respect of personally identifiable information or your privacy practices?
*
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Yes
No
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30
Have you ever received a complaint relating to the handling of someone's personally identifiable information?
*
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Yes
No
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31
Have you suffered any loss or has any claim (that this type of policy would cover) whether successful or not been made against you?
*
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Yes
No
Type option 3
Type option 4
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32
Please tell us your % of turnover per state
% of turnover per state
QLD
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NSW
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VIC
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ACT
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SA
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TAS
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WAS
Row 6, Column 0
Row 6, Column 1
NT
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Row 7, Column 1
QLD
NSW
VIC
ACT
SA
TAS
WAS
NT
% of turnover per state
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% of turnover per state
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Row 1, Column 1
% of turnover per state
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Row 2, Column 1
% of turnover per state
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Row 3, Column 1
% of turnover per state
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Row 4, Column 1
% of turnover per state
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Row 5, Column 1
% of turnover per state
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Row 6, Column 1
% of turnover per state
Row 7, Column 0
Row 7, Column 1
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33
Fantastic! You're finished. Thank you for completing the form, we know this type of insurance proposal form is a bit of slog...Before your hit that submit button please tell us where you have heard about us?
*
This field is required.
A friend
Facebook / Instagram
I'm already a Reef IB client :)
A Reef IB client referred me.
Google
Other
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