Cyber Proposal
Everest Medical Indemnity is a registered trading entity of Everest Risk Group Pty Ltd and Corporate Authorised Representative (No 276869) of Insurance Advisernet Australia Pty Ltd (AFSL 240549)
Name of Applicant(s) Requesting Insurance:
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Please note: the entity must be “Pty Ltd” to qualify for cover
Year Established:
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Applicants Principal Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Name:
First Name
Last Name
Your Email Address:
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Confirmation Email
Phone Number
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-
Area Code
Phone Number
Company Website:
Commencement Date of Insurance:
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/
Day
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Month
Year
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Occupation:
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Australian Business Number (ABN):
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Has any proposed Applicant been declined, had cancelled or non-renewed any insurance policies for any of the coverages for which they are applying?
Yes
No
Underwriting Questions:
Yes
No
Are you Domiciled In Australia
Do you use operating systems with embedded firewalls and anti-virus protection software (such as Windows or MAC OS X), or run commercially licensed separate firewall or anti-virus protection software?
Are all mobile devices (such as laptops, tablets, smartphones and memory sticks) password protected?
Are you compliant with the Payment Card Industry (PCI) Standards, or if not compliant, do you process, transmit or store LESS than 1,000,000 financial transactions or records containing individual's personal information?
Are you aware of any matter that is reasonably likely to give rise to any loss or claim under such insurance, or have you suffered any loss or any claim including but not limited to a regulatory, governmental or administrative action brought against you, or any investigation or information request concerning any handling of personally identifiable information?
Is more than 25% of your revenue derived from the USA or Canada?
Do you outsource any part of your network, including storage?
Are all requests to alter supplier and customer details including bank account details, independently verified with a known contact for authenticity?
Do you ensure that at least two members of staff authorise any transfer of funds, signing of cheques (above $2,000) and the issuance of instructions for the disbursement of assets, funds or investments?
Please state the total number of employees located in the following states and overseas:
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Number
NSW
VIC
ACT
QLD
SA
WA
TAS
NT
O/S
Signature
Name
*
First Name
Last Name
Title
*
Date
*
/
Day
/
Month
Year
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Submit
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