SME Micro Cyber Insurance Application

SME Micro Cyber Insurance Quote Application

Martial Arts Australia Insurance Services ABN:31 632 785 329Corporate Authorised Representative: 001283262 of United Insurance Group Pty Ltd ABN 31 131 564 522 Australian Financial Services License: AFSL 327131
Please Note: The Insurer uses a number of elements to calculate your premium. Fill in the form with what you feel is the appropriate information and we will call you to clarify anything extra we need.
Business Information
Insured ABN / ACN
Is the policyholder a subsidiary, franchisee or part of a larger group?
Yes, please provide details:
Contact name of policy holder

First NameLast Name
Email
example@example.com
Mobile
Insured Business Name - Legal Trading Entity:
Website
Business activities / occupation
Do you perform work for the defence industry or Federal Government or are you a member of the Defence Industry Security Program (DISP)?
What percentage of total revenue is from online or e-commerce activities?
Client Security Officer Details – Name/Role/Email/Phone
Please provide the contact details of the person who is responsible for cyber security
Number of Employees
Operations by State / Territory
Policy Holder's Principal Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Estimated revenue for the coming 12 month period by territory:

Rows	Australia / NZ	EU / UK	USA	Rest of world	TOTAL
$

Stamp Duty - for calculating stamp duty, outline the breakdown of revenue (000’s) or employee numbers by state/region:

Rows	NSW	VIC	QLD	WA	SA	NT	TAS
Employee Numbers

Is policyholder stamp duty exempt? If Yes, please provide a copy of the exemption letter.
Date you require Insurance to Start
Coverage Questions
How frequently do you provide security awareness training to your employees?
Have you implemented a critical security patch management process for your IT systems?

Is Multi-Factor Authentication (MFA*) required for all users to access the following systems/platforms/services?

Rows	Yes	No
All remote access to the network?
Web-based email?
Admin/privilege service accounts?
Cloud resources, including back ups?

Is your back up environment: (select all that apply)
How frequently do you take regular backups of critical data and systems?
Do you keep a copy of critical backups offline, segregated from and inaccessible to your network?
After enquiry, within the past 5 years, are you aware of any losses, claims, circumstances, cyber events, privacy breaches, regulatory investigations, crime or social engineering incidents which have impacted, or could adversely impact your business or give rise to a claim under a cyber policy?
No or Yes. If Yes, provide details, date of loss, total impact cost, including all business interruption, remediation costs and other loss? Nature of loss. Steps and controls that were implemented after loss.
Have you had any unforeseen down time to your website or IT network of more than 8 hours?
No or Yes. If yes, provide details including duration, how it was resolved and any cost to you
Optional Cover

Rows	YES	NO
Do you want Optional Cover for Non-IT Contingent Business Interruption and System Failure?
Do you want Optional Cover for Criminal Financial Loss?
Do you want to include cover for socially engineered theft?
Are all new payees, and changes to existing payees’ banking details, double authenticated with the payee?
Do transfers > $10,000 require dual signature or supervisor / manager sign off?
After enquiry, have you within the past 5 years suffered a crime, fidelity or computer crime loss? If Yes, please provide details to broker
Do you want Optional Cover for Tangible Property?

Limit for Criminal Financial Loss
Sublimit for socially engineered theft
Tell us about your critical components, service providers and supplies.
DECLARATION
I/We the undersigned duly authorised person(s) declare that:
i. I am/we are authorised by each of the Proposers to sign this Proposal Form; and
ii. the above statements are correct, true and complete; and
iii. no information material to this Proposal Form has been withheld; and
iv. I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure; and
v. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure; and
vi. I/we understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance; and
vii. I/We undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and
viii. I/we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance.
Name

FULL NAMEDATED
This application form will be used to create a letter of offer for the nominated insurances you have selected. Upon your acceptance of this offer we will create the rest of documents (invoice / certificate of currency etc).

Payment Methods: Wait for the Broker / Insurer invoice to make payment (options apply).

Send all correspondence to: Martial Arts Australia Insurance Services
Email: gslater@martialartsinsurance.com.au
DISCUSS - P: 03 8201 9908 URGENT: 0451 331 958 (Text 24/7)
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SME Micro Cyber Insurance Quote Application

Business Information

Coverage Questions

Optional Cover