Cyber Insurance Quote Request
Business Details:
Legal name
*
Operating name (if any)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Main phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Main email
*
example@example.com
Website
Legal entity:
*
Sole proprietorship
Partnership/Joint venture
Incorporation
Other
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Contact Person Details:
Contact person's full name
*
First Name
Last Name
Contact person's phone no.
*
Please enter a valid phone number.
Format: (000) 000-0000.
Contact person's email
*
example@example.com
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Cyber Insurance Details:
Current insurance company name (if applicable)
Current insurance policy number (if applicable)
Effective/renewal date
*
-
Month
-
Day
Year
If renewal was not being offered, please explain.
Have you had a personal data breach, other security breach or other cyber related incident (such as loss of money) in the past 3 years that would have or could have led to a claim or notification under any of these cyber covers had they been in place at the time? If YES, please state the total cost and details:
Have you been subject to legal or regulatory action in relation to data privacy in the past 3 years? If YES, please state the total cost and details:
Have you ever received any complaint or claim about personal or confidential data? If YES, please state the details:
If you answered YES to any of the three question above, please provide details of any measures, including professional advice, that have been taken to prevent the recurrence of the situation which gave rise to each claim.
Have you ever had any cyber insurance declined, cancelled or withdrawn? If YES, please state the details:
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Cyber Risk Assessment:
Business start date
*
-
Month
-
Day
Year
Date
No. of years of related prior experience
*
Please provide a full description of the business activities including any subsidiary or associated companies to be covered.
Please provide the best estimated values for the following: If N/A, then enter 0
*
Rows
Revenue
Payroll
# of Employees
a) Canada
b) US
c) Others
The amount of personal data records held or processed by you, including customer and employee data records
*
up to 100,000
up to 500,000
up to 1,000,000
Other
The number of payment card information (PCI) transactions processed
*
up to 20,000
up to 1,000,000
up to 6,000,000
over 6,000,000
Other
Are you compliant with the most recent applicable Payment Card Industry Data Security Standard (PCI-DSS)?
*
Yes, Level 1
Yes, Level 2
Yes, Level 3
Yes, Level 4
N/A
Are you Cyber Essentials accredited?
*
Yes
No
Are you Cyber Essentials Plus accredited?
*
Yes
No
Do you comply with other information security or privacy standards e.g. ISO 27001?If “YES”, please provide details:
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You have a dedicated officer or designated person(s) responsible for information security reporting to senior management.
*
Yes
No
You have a dedicated officer or designated person(s) responsible for data protection reporting to senior management.
*
Yes
No
Number of employees engaged in information security:
Your annual expenditure on information security:
You backup your data and undertake an annual restoration test of these backups.
*
Yes
No
The backup is undertaken daily?
*
Yes
If not, how often
Your backup is separate from your main network?
*
Yes
No
More than one backup is taken?
*
Yes
No
Default passwords for all your systems are changed immediately after purchase or development?
*
Yes
No
Your administrative passwords are separate?
*
Yes
No
You have a strong password policy across your business i.e. long and complex passwords?
*
Yes
No
You use anti-virus, anti-spyware or similar malware protection software, which are automatically updated and manually updated when necessary?
*
Yes
No
You automatically patch your computer systems and apply manual critical patches and close other known vulnerabilities as soon as possible, but not later than 14 days from notification?
*
Yes
No
You use perimeter firewalls to protect your network and computer systems?
*
Yes
No
Please tick the boxes below for the additional controls that you use including those provided by a third party.
Advanced Endpoint protection
Application whitelisting
Database Encryption
Data loss prevention
DMARC
Multi-factor Authentication
Any additional controls? Please provide details
By submitting the above-mentioned information, the applicant declares that all statements made in the questionnaire and the information contained in documents submitted with it are true. Submitting of this document does not bind the applicant to complete the insurance, but it is agreed that the questionnaire shall be the basis of the contract, should a policy be issued.
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