Data Breach Coverage Inquiry Form

1
Legal Business Name* This field is required.Including DBA names.
2
Practice Owner's Name* This field is required.
First Name
Last Name
3
Practice Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Practice website
5
Insurance Contact NameIf different from practice owner.
First Name
Last Name
6
Phone Number* This field is required.
Area Code
Phone Number
7
Email* This field is required.For security reasons, please provide a private email address not shared by multiple employees.
example@example.com
8
Practice legal structure* This field is required.
Sole proprietor
Partnership
Corporation
LLC
PLLC
Other
9
Years in Business:* This field is required.
10
Estimated gross annual revenue:* This field is required.
USD
11
Prior fiscal year gross annual revenue:* This field is required.
USD
12
Practice Federal Employer ID Number (FEIN)
13
Number of full-time employees* This field is required.
14
Number of part-time employees* This field is required.
15
Estimated total annual payroll cost:* This field is required.
USD
16
How many protected records are held by the practice?* This field is required.This is the number of unique individual personal/confidential proprietary records which are stored on a computer system including, but not limited to: employees, retirees, customers, partners, and third parties' information
< 250 Records
250-499 Records
500-999 Records
1,000-2,499 Records
2,500-4,999 Records
5,000-9,999 Records
10,000-24,999 Records
25,000-49,000 Records
50,000-99,999 Records
Other
17
In the past three years have you had any actual or potential data breach incidents or claims?* This field is required.
YESNO
18
Do you accept payment card (credit/debit card) transactions?* This field is required.
YESNO
19
Is the practice PCI compliant?* This field is required.
YESNO
20
Does the practice have antivirus and firewalls controls in place?* This field is required.
YESNO
21
Does the practice encrypt sensitive data?* This field is required.
YESNO
22
Does the practice have critical data backup and recovery procedures?* This field is required.
YESNO
23
Does the practice have a formal cyber incident response plan in place?* This field is required.
YESNO
24
Does the practice use Multi-factor Authentication (MFA) for business emails?* This field is required.
YESNO
25
Does the practice use Multi-factor Authentication (MFA) for network/system access, and/or VPNs?* This field is required.
YESNO
26
Does the practice rely on cloud computing, software-as-a-service, or any other outsourced computer/server hosting for revenue-generating operations?* This field is required.
YESNO
27
Do you currently have business property and general liability coverage through the AVMA Trust program?* This field is required.Also referred to as a business owner’s policy, BOP, or package policy.
YESNO
Should be Empty: