Referral Partner Profile
Please complete the fields below and provide as much detail as possible. Your referral partner agreement, enablement tools, training and additional materials will be customized based upon your inputs. This form uses a 256-bit SSL connection and is PCI, GDPR and CCPA compliant. All submissions are encrypted with RSA 2048 and automatically deleted.
Organization Information`
*
Rows
Please provide details:
Full Legal Name of Organization
DBA or Trade Name(s)
Street Address
City
State
Zipcode
Organization Main Phone
Organization Main Email Address
Website
Organization Specifics
Rows
Please provide details:
Year Established
Number of Employees
Number of IT Staff
Number of Security Staff
Approximate Number of Customers
Approximate Number of End Users
Approximate Number of Endpoints
Organization Annual Revenue
Under $1.0mm
$1.0mm-$2.5mm
$2.5-$5.0mm
$5.0-$10.0mm
Over $10.0mm
Please upload your logo (high resolution).
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of
Team Members
Please tell us about your team members so we can connect with the appropriate staff at your organization. If a field is not applicable please simply leave it blank.
Team Members - Main Contact
*
Rows
Please provide details:
Who will be our Main Contact?
Main Contact Title
Main Contact Email Address
Main Contact Phone Number
Team Members - Head of Sales
Rows
Please provide details:
Head of Sales Name
Sales Contact Email Address
Sales Contact Phone Number
Team Members - Head of Marketing
Rows
Please provide details:
Head of Marketing Name
Marketing Contact Email Address
Marke
ting Contact Phone Number
Team Members - Head of IT
Rows
Please provide details:
Head of IT Name
IT Contact Email Address
IT Contact Phone Number
Team Members - Head of Security
Rows
Please provide details:
Head of Security
Security Contact Email Address
Security Contact Phone Number
Industry + Offerings
Please tell us about the primary industries that you serve and your current offerings.
Which of the following regulated industries do you support?
Financial Services
Insurance Brokerage
Healthcare
Government
NONE
Other
Which of the following products do you currently offer?
Insurance Products
Financial Services
Legal Services
Accounting Services
General IT Services
Bodyguard or Protection Services
Endpoint Detection + Response
Managed Detection + Response
Advanced Email Protection
Advanced Cloud Protection
Multifactor Authentication
Remote Access
Disaster Recovery
Business Continuity Planning
Incident Response Planning
Identity Theft Protection + Resolution
Application Safelisting
Privileged Access Management
Password Management
Patch + Vulnerability Management
Encryption
Zero Trust Segmentation
Edge Network Protection
Log Resilience
Cyber Security Policy
Other
How often do you evaluate the products you are offering?
NEVER
Monthly
Quarterly
Annually
Do you currently have Cyber Liability Insurance in force?
Yes
No
What type of Cyber Liability Insurance do you have in force?
Standalone Policy
Rider (Combined w/BOP, General Liability, etc)
Unsure
Cyber Liability Insurance Information
Rows
Please provide details:
Current Carrier for Cyber Liability
Amount of Cyber Liability Coverage
Annual Premium for Cyber Liability
Renewal Date of Cyber Liability
Submitter Name
*
First Name
Last Name
Submitter Email
*
example@example.com
Date Submitted
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
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