Basic information
Company name
*
Address
*
Including Floor, Suite or Unit Number
Street Address Line 2
City
State / Province
Postal / Zip Code
Website
*
Applicant's email address
*
example@example.com
Annual revenue of last fiscal year
*
Number of company employees
*
Security Contact Information
Name
*
Email
*
example@example.com
Phone
*
Format: (000) 000-0000.
Industry
*
*
I confirm that the applicant does NOT operate in any of the following: Cannabis, Online Gambling, Adult Content
Insurance and claims
Does the applicant currently carry a standalone cyber policy?
*
Yes
No
If yes, indicate expiration date:
*
/
Month
/
Day
Year
Date
Claim activity - In the last 5 years, has the company suffered any cyber event, unscheduled network outage over 4 hours, loss or claim that would fall within the scope of the policy for which the applicant is applying?
*
Yes
No
If yes, please complete the following details:
Loss amount
*
Date of notice
*
/
Month
/
Day
Year
Date
Event description
*
What has the applicant done since the event to prevent future claims?
*
The applicant has not had any legal action and\or regulatory action brought or threatened against them in the last five years as a direct result of a cyber event.
The applicant or any other person or organization proposed for this insurance is not aware of any fact, circumstance, situation, event, or wrongful act which reasonably could give rise to a cyber event, loss, or a claim being made against them that would fall within the scope of the policy for which the applicant is applying?
Within the last 3 years, the applicant has not been subject to any complaints concerning the content of its website, advertising materials, social media, or other publications.
Security Controls
1. Multi-factor authentication (MFA) - Does the applicant have multi-factor authentication enabled on email access, remote access & network administration?
*
Yes
No
I don’t know
2. How many PII, PHI or PCI records does the applicant collect, process, store, transmit, or have access to?
*
No records
< 100K
100K-250K
250K-500K
500K-1M
>1M
I don’t know
3. How many biometric information records or data (i.e fingerprints, retinal scans, etc.) does the applicant collect, process, store, transmit, or have access to that can be used to uniquely identify a person?
*
No records
< 100K
100K-250K
250K-500K
500K-1M
>1M
I don’t know
4. Does the applicant keep offline backups for all critical data that are disconnected from its network or store backups with a cloud service provider?
*
Yes
No
I don’t know
If yes, how frequently does it run?
*
Continuously
Daily
Weekly
Monthly
More than monthly
I don’t know
5. Does the applicant implement encryption on laptop computers, desktop computers, and other portable media devices for all sensitive information?
*
Yes
No
I don’t know
6. What is the estimated annual volume of payment card transactions (credit cards, debit cards, etc.)?
*
No payment card transactions
< 100K
100K-500K
500K-1M
>1M
I don’t know
Is the applicant or their outsourced payment processor PCI-DSS compliant?
*
Yes, applicant does not use outsourced payment processor
Yes
No
I don’t know
7. Does the applicant require a secondary means of communication to validate the authenticity of funds transfers ACH, wire, etc requests by at least 2 employees before processing a request in excess of $25,000?
*
Yes
No
I don’t know
8. Does the applicant enforce procedures to remove content (including third party content) that may infringe or violate any intellectual property or privacy right?
*
Yes
No
I don’t know
Are you an insurance agent submitting on behalf of your client?
*
Yes
No
Agent Name
*
Name of Agency
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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