Cyber Insurance Intake Form

All required questions are marked by an asterisk (*)

Which best describes the role of the person completing this form?*

Licensed Insurance AgentMSP or MSSPInternal ITApplicant looking for a quote

How did you hear about UKON?*

Through my MSPThrough my agentI came across UKON for my own insurance

Applicant Entity Name*

Applicant Contact Name*

First NameLast Name

Applicant Title

Applicant Contact Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Extension

Does the applicant own or control any subsidiary entities by 50% or more?

YesNoI don't know

Subsidiary Entity(s) if applicable:

Attach a list of all subsidiaries, affiliated companies or entities owned by the Applicant and include a description of (1) the nature of operations of each subsidiary, affiliated company or entity, (2) its relationship to the Applicant and (3) the percentage of ownership by the Applicant.

Does the applicant have an active cyber policy in force?

YesNo

Please upload policy if available:

Applicant is domiciled in the USA

Entity Location Street Address*

Entity City*

Entity State*

Entity Zip Code*

Does the applicant have a website?*

YesNo

Primary Website*

If no website, please proceed to the next question.

Industry/Sector*

Industry NAICS Code*

The NAICS code can be completed in several ways:

Google: Search on Google, and once you discover the correct NAICS code, enter it under "Industry NAICS Code". For example, the first result on Google for “NAICS Kindergarten” is 624410.

Autocomplete: Begin typing the business’s industry type and choose from the selections provided.

Do any of the applicant's operations include the following? (select all that apply)*

Adult ContentCannabisCryptocurrency or BlockchainGamblingDebt Collection AgencyManaged IT Service Provider (MSP or MSSP)Payment Processing (e.g. as a payment processor, merchant, acquirer, or point of sale system vendor)None of these apply to the applicant

You've selected Payment Processing under the applicant operations. This is rare since most applicants outsource payment processing to a third-party when accepting credit cards. Please confirm before proceeding.

Is the applicant a franchisee or franchisor?

YesNo

I confirm that the applicant does NOT operate in any of the following: Cannabis, Online Gambling, Adult Content, MSP, or MSSP.

Year Established*

Number of Employees*

Revenue - Prior Fiscal Year

Revenue - Est. Current Fiscal Year

Revenue - Est. Next Fiscal Year

Revenue - Prior Fiscal Year

Revenue - Est. Current Fiscal Year*

Revenue - Est. Next Fiscal Year

Percentage Domestic Sales

Have any of the applicants principals, partners, directors, risk managers, or employees during the last three (3) years, sustained any loss, filed a claim, or had any claim made against them, whether insured or not, involving the type of insurance(s) being requested in this application?*

YesNoI don't know

If yes, what is or was the expected total financial impact to the applicant and its insurer?

Please select all applications where the Applicant has MFA (multi factor authentication) enabled:*

Additional Notes - MFA

Optional

Desired Aggregate Limit

Select up to two.

Desired Aggregate Limit(s)

Are any of the above requested limits due to a contract requirement?

YesNo

Please provide the contract wording if available. Most carriers require the wording to approve higher limits.

With the LOTA cyber insurance intake form, you can determine applicant eligibility across 45+ cyber carriers with 99% accuracy.

General Information - Required

Core Security Controls - Required

Additional Security Controls

Partner Information