Cyber Liability

Cyber Liability
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Your duty of disclosure

The insurer may ask you questions that are relevant to their decision to insure you and on what terms. If they do, you must tell the insurer anything that you know and that a reasonable person in the circumstances would include in their answer. You have this duty until the insurer agrees to insure you. If you do not tell them something you are required to, they may cancel your insurance contract or reduce the amount they will pay you if you make a claim, or both. If your failure to tell the insurer is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed.

By proceeding you confirm you have read and understood this duty

Refer to Financial Services Guide to learn more about the financial services offered by APBI and the Insurance Brokers Code of Practice our team adheres to.
Section 1: Details of Applicant
Please select Insured Entity Type*
ABN/ACN
Insured Name*
Trading Name
Insured’s Registered Address:*
Suburb*
Post Code*
State*
Email*
Please make sure it is valid, submission links and progresses will be sent to this mail address later
Occupation/Business Description (all business activities including the activities of any related entities)*
Annual Revenue / Turnover for the last 12 months: (AUD) $ *
If new or trading less than 12 months, please estimate annual revenue / turnover for next 12 months.
Staff Size*
Include all principals, partners, directors, and employees (full time, part time and casual staff, interns and volunteers).
Insured’s Website Address:

	Percentage %
SA
NSW
ACT
QLD
VIC
TAS
WA
NT
O/S*

Section 3 : Cyber Liability & Privacy Protection
Does the Insured use operating systems with embedded firewalls and anti-virusprotection software (such as Windows or Mac OS X), or run commercially licencedseparate firewall or anti-virus protection software?*

YesNo
Are all mobile devices (such as laptops, tablets, smartphones and memorysticks) password protected?*

YesNo
Is the insured compliant with Payment Card Industry Standards (if applicable), as set out by the PCI Security Standards Council (PCI SSC)*

YesNo
Does the Insured outsource any part of their network, including storage?*

YesNo
If YES, to whom?
How many Personally Identifiable Information (PII) records does the insured hold? *

Section 4 : Declaration
SIGNING THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR THE INSURER TO COMPLETE THIS INSURANCE

The undersigned declares that the statement and particulars in this Proposal Form are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agree that should any of the information given by us alter between the date of this proposal and the inception date of the insurance to which this proposal relates, the undersigned will give immediate notice thereof. The undersigned agrees that the Underwriters may use and disclose our personal information in accordance with the ‘Privacy Collection Statement’ above.

The undersigned acknowledges that they have read this Proposal Form, including all Important Notices, as well as the policy wording and associated endorsements and are satisfied with the coverage provided, including the limitations and restrictions on
coverage.

The undersigned agrees that this Proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.

TO BE SIGNED BY THE INSURED FOR WHOM THIS INSURANCE IS INTENDED FOR
Full Name:
Position:
Signature

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Cyber Liability

Section 1: Details of Applicant

Section 2: General Questions

Section 3 : Cyber Liability & Privacy Protection

Section 3 : Cyber Liability & Privacy Protection

Section 4 : Declaration