Sayata Cyber Liability Application

Basic information
Company name*
Address*

Including Floor, Suite or Unit Number

Street Address Line 2

CityState / 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*
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?*

YesNo
If yes, indicate expiration date:*

MonthDayYear
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?*

YesNo
If yes, please complete the following details:
Loss amount*
Date of notice*

MonthDayYear
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?*

YesNoI don’t know
2. How many PII, PHI or PCI records does the applicant collect, process, store, transmit, or have access to?*

No records< 100K100K-250K250K-500K500K-1M>1MI 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< 100K100K-250K250K-500K500K-1M>1MI 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?*

YesNoI don’t know
If yes, how frequently does it run?*

ContinuouslyDailyWeeklyMonthlyMore than monthlyI don’t know
5. Does the applicant implement encryption on laptop computers, desktop computers, and other portable media devices for all sensitive information?*

YesNoI don’t know
6. What is the estimated annual volume of payment card transactions (credit cards, debit cards, etc.)?*

No payment card transactions< 100K100K-500K500K-1M>1MI don’t know
Is the applicant or their outsourced payment processor PCI-DSS compliant?*

Yes, applicant does not use outsourced payment processorYesNoI 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?*

YesNoI 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?*

YesNoI don’t know
Are you an insurance agent submitting on behalf of your client?*

YesNo
Agent Name*
Name of Agency*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Basic information

Security Contact Information

Insurance and claims

Security Controls