Cyber Liability
Business Name
*
Business Address
Description of business activities
Number of years in business
Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
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Annual Turnover
Do you use operating systems with embedded firewalls and anti-virus protection software (such as Windows or MAC OS X), or run commercially licensed separate firewall or anti-virus protection software?
Yes
No
Are all mobile devices (such as laptops, tablets, smartphones and memory sticks) password protected?
Yes
No
Are you compliant with the Payment Card Industry (PCI) Standards, or if not compliant, do you process, transmit or store LESS than 1,000,000 financial transactions or records containing an individual’s personal information per year.
Yes
No
Are you aware of any matter that is reasonably likely to give rise to any loss or claim under such insurance?
Yes
No
Have you suffered loss or claim including but not limited to a regulatory, government or administrative action brought against you, or any investigation or information request concerning any handling of personally identifiable information?
Yes
No
Do you outsource any part of your network, including storage?
Yes
No
Is more than 25% of your revenue derived from the USA or Canada?
Yes
No
Do you wish to have cover for Social Engineering, Phishing & Cyber Fraud?
Yes
No
Do you operate in or undertake business activities in the Medical Services / Veterinary Services industry
Yes
No
Do you operate in or undertake business activities in the Healthcare / Health Services industry
Yes
No
Have you sustained any cyber claims in the past 5 years?
Yes
No
Are there any other facts that an insurer should be aware of?
Yes
No
If yes to either of the above two questions, please advise details:
Submit
Should be Empty: