Cyber Insurance Form
General Information
Insured Name
First Name
Last Name
Website and Email Domain(s) Please list all website addresses including web and email domains:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Industry
Number of Employees
Turnover
Gross Profit / Net Turnover
GST Registered?
Yes
No
ABN
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During the past three years, did the Named Insured experience a cyber incident, claim or loss, whether insured or not, which could have been covered under a policy similar to the proposed insurance, this includes but is not limited to any:
Actual or reasonably suspected data breach or security failure, including notifying consumers or third parties of a data breach or security failure;
Claims or complaints with respect to privacy injury, breach of information or network security, unauthorised disclosure of information, defamation, or content infringement;
Government action, investigation, or subpoena regarding any alleged violation of a privacy law or regulation; or
Actual or attempted extortion demand with respect to (insured’s) data or computer systems.
If yes, please explain the cyber incidents and/or claims.
Does the Named Insured have knowledge or information regarding any fact, circumstance, situation, or event that could reasonably give rise to a claim or loss under the proposed insurance?
Yes
No
If yes, please explain
Does the Named Insured implement encryption on laptop computers, desktop computers, and other portable media devices?
Yes
No
Does the Named Insured collect, process, store, transmit, or have access to any Payment Card Information (PCI) or Personally Identifiable Information (PII), other than employees of the Named Insured?
Yes
No
If yes, what is the estimated annual volume of payment card transactions (credit cards, debit cards, etc.)?
If yes, how many PII records does the Named Insured collect, process, store, transmit, or have access to?
Does the Named Insured maintain at least weekly backups of all sensitive or otherwise critical data and all critical business systems offline or on a separate network?
Yes
No
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For which of the following services does the Named Insured enforce Multi-Factor Authentication (MFA)?
Email
Virtual Private Network (VPN)
Remote Desktop Protocol (RDP), RDWeb, RD Gateway, or other remote access
Network / cloud administration or other privileged user accounts
Does the Named Insured require a secondary means of communication to validate the authenticity of funds transfer requests before processing a request in excess of $5,000?
Yes
No
Does the Named Insured require a secondary means of communication to validate the authenticity of funds transfer requests before processing a request in excess of $5,000?
Yes
No
Within the last 3 years has the Named Insured been subject to any complaints concerning the content of its website, advertising materials, social media, or other publications?
Yes
No
Does the Named Insured enforce procedures to remove content (including third party content) that may infringe or violate any intellectual property or privacy right?
Yes
No
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Optional Technology Errors and Omissions Cover
Please describe the Named Insured’s use of technology in delivering its product and/or services.
Within the last 3 years has the Named Insured been subject to a dispute or claim arising out of a technology error or omission in excess of $25,000?
Yes
No
Does the Named Insured have remote access to administer, troubleshoot, monitor, or update their customers’ networks and/or systems?
Yes
No
Does the Named Insured participate directly in or sell technology products/services specifically designed for any of the following industries?
Adult Entertainment
Automotive
Aviation
Blockchain
Cannabis
Cryptocurrency
Financial Services
Gambling
Healthcare
Internet of Things
Military/Defence
Payment Processing
Professional Services (Legal, Medical, A&E, or other licensed professional services)
Point of Sale (POS) Software/Hardware/Reseller
How often are the Named Insured’s services provided by written agreement or contract?
100% OF AGREEMENTS OR CONTRACTS
≥ 50% OF AGREEMENTS OR CONTRACTS
< 50% OF AGREEMENTS OR CONTRACTS
0% OF AGREEMENTS OR CONTRACTS
Identify the standard risk mitigating clauses or methods contained within the Named Insured’s agreements or contracts. (Select all that apply)
CUSTOMER ACCEPTANCE / FINAL SIGN OFF
DISCLAIMER OF WARRANTIES
HOLD HARMLESS AGREEMENTS THAT BENEFIT NAMED INSURED
LIMITATION OF LIABILITY
EXCLUSION OF CONSEQUENTIAL DAMAGES
INDEMNIFICATION CLAUSE
BINDING MANDATORY ARBITRATION
PROJECT PHASES / MILESTONES
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