CYBER APPLICATION
NAMED INSURED
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WEBSITE DOMAIN(S)
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
INDUSTRY DESCRIPTION
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NUMBER OF EMPLOYEES
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REVENUE (EXPECTED OVER THE NEXT 12 MONTHS)
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UNDERWRITING QUESTIONS:
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Rows
YES
NO
IF YES, PLEASE EXPLAIN
Within the last 3 years has Named Insured suffered any cyber incidents
resulting in a claim in excess of $25,000?
Is Named Insured aware of any circumstances that could give rise to a
cyber claim?
Does Named Insured enable disk encryption on laptops, desktops, and
other portable media devices?
Does Named Insured accept credit cards or collect Personally Identifiable Information (PII) or Protected Health Information (PHI) from its customers? (This does not include employees of Named Insured.)
Does Named Insured have procedures to back up, archive, and restore
sensitive data and critical business systems?
Does Named Insured require dual control when transferring funds in
excess of $25,000?*
Within the last 3 years has Named Insured been subject to any complaints concerning the content of its website, advertising materials, social media,
or other publications?
Does Named Insured have procedures to remove content (including third party content) that is libelous, infringing, or otherwise controversial?
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