Client Quote Submittal - Beltex Production

Are you an Managed Services or Technology Service Provider (MSP/TSP)? Do not fill this application for insurance out, but rather click here for more information on how Beltex can help insure you and your customers.
Your technology partner has passed your information along to us because you had expressed interest in a Commercial Cyber Insurance Policy. If you aren't quite sure why you have gotten this, please reach out to them at {mspemail}.

For your convenience, they have pre-filled a number of fields for you, but please ensure their accuracy before submitting this form to get an insurance quote.

Thank you!

Beltex Insurance
MSP Business Name
MSP Name

First NameLast Name
MSP Email
example@example.com
What do you call your security bundle?
ex "Advanced Security Bundle"

Your Basic Business Information
Product ID
Business Entity Name*
Applicant Name*

First NameLast Name
Applicant Email*
example@example.com
Applicant Phone Number*
Please enter a valid phone number.
NAICS Code - Description*
Date established*

MonthDayYear
Date
Type of Ownership Structure*
Company revenue in dollars*
Number of employees*
Any cyber liability claims in the last 3 years?*

YesNo
During the last three (3) years, has Your organization suffered a security breach requiring customer or third-party notification according to state or federal regulations, cyber extortion or business interruption arising from a cyber event?*

YesNo
Has your organization ever been a party to any of the following: a. Civil or criminal action or administrative proceeding alleging violation of any federal, state, local or common law?*

YesNo
Has your organization ever been a party to any of the following: b. Is there currently any pending litigation, administrative proceeding or claim against the named applicant, organization and/or any of the prospective insured?*

YesNo
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Is your billing address the same as your physical address?

YesNo
Billing Address

Street Address

Street Address Line 2

CityState

Zip Code
Is your mailing address the same as your physical address?

YesNo
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Domain Name*
You are authorizing Beltex Insurance Agency LLC and contracted third parties to perform an external scan for commonly vulnerable ports and services for this domain and other associated subdomains. Any issues identified may be sent to you and your technology partner and yourself for follow-up.