Lawyers' Premium Indication Form

CYBER

PREMIUM INDICATION
COMPANY INFORMATION
Company*
Contact*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
E-mail*
example@example.com
Year Established*
# of Employees*
Revenue*
INSURANCE INFORMATION
Do you currently purchase Cyber Coverage?*

YesNo
Requested Liability Limits*

$250,000$500,000$750,000$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000
Requested Deductible*

$1,000$2,500$5,000$10,000
Policy Information*
Current Policy Prior Acts Date*

MonthDayYear
Attach Your Policy Declarations Page and Endorsements

Cancelof
Have you had a Cyber claim(s) in the past 5 years?*

YesNo
Cyber Claim(s) Information:
NETWORK SECURITY
Check All Systems Used:

Anti-Virus InstalledFirewalls are UsedBack-up RegularlyHIPPA ComplaintPCI Compliant
Systems Continued:

Intrusion Detection InstalledSoftware Upgraded RegularlyOffer Virtual Private NetworksMulti-Factor AuthenticationPerform 3rd Party Testing
INFORMATION SECURITY
Do you receive, process, transmit or maintain as part of your business:

Credit Card DataSocial Security NumbersMedical InformationDate of BirthBank Account InformationIntellectual Property of Others
Approximate number of maintained files:
Are all of the sensitive files and client information encrypted?

YesNo
Should be Empty:

CYBER