Cyber Insurane Questionnaire
Please fill out the information below to get a cyber risk management report and stand alone cyber insurance proposal. Work with IT to answer the questions to the best of your knowledge and if you are uncertain, please mark no.
Office Name
*
Who is filling out the form
*
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Practice Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
IT Company Name
*
Primary IT Contact Person
*
First Name
Last Name
HIPAA vendor
HIPAA vendor contact person
First Name
Last Name
Are they doing an annual HIPAA compliance?
Yes
No
Does your office maintain at least weekly backups of all sensitive or critical data and critical business systems offline or on a separate network?
*
Yes
No
Is Multi-Factor Authentication (MFA) enforced for email?
*
Yes
No
Is MFA enforced for VPN access?
*
Yes
No
Is MFA enforced for RDP, RDWeb, RD Gateway, or any other remote-access method?
*
Yes
No
Is MFA enforced for network administration, cloud administration, and other privileged/admin accounts?
*
Yes
No
Number of patient records
Under 100k
100k-500k
500k-1million
Over 1 million
Number of employees
List of all websites and domains
Estimated annual revenues
Submit
Should be Empty: