Cyber Liability Application

NOTICE

Cyber liability policies are generally written on a claims-made basis: only claims first made during the policy period (and reported as the policy requires) are covered. This application is not a binder.

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Step 1 of 4 - General Information

25%

Please answer every question and type directly into the fields. Choose N/A where offered. This application is not a binder.

General Information

Name of Applicant (Insured Organization)*

Address*

Address City State Zip Code

Contact name*

E-mail*

Telephone*

Date Established

State of Incorporation

Website

Revenues - last fiscal year ($)

Please enter a number greater than or equal to 0.

Estimated revenues - next 12 months ($)

Please enter a number greater than or equal to 0.

Description of business operations

Number of employees

Please enter a number greater than or equal to 0.

Is the Applicant engaged in any of the following? (check all that apply)

Adult content

Cannabis

Cryptocurrency or blockchain

Debt collection

Gambling

Managed IT services (MSP / MSSP)

Payment processing

None of these

Limit requested

Retention / deductible requested

Requested effective date

Type of Private Information - Estimated Number of Records

Personal Identifiable Information (PII) - (i.e. - Social Security, Customer Info. or Biometric Data) - estimated number of records

Please enter a number greater than or equal to 0.

Personal Healthcare Information (PHI) - (i.e. – Medical Records, Health Insurance Account) - estimated number of records

Please enter a number greater than or equal to 0.

Financial Information - (i.e. – Credit Cards, Bank Account Information, Money/Securities) - estimated number of records

Please enter a number greater than or equal to 0.

Third Party Corporate Information - (i.e. – Non-Disclosure Contract)

Yes

Does the Applicant currently have cyber insurance?

Yes

Current cyber carrier

Current limit

Expiration date

In the last 3 years, has any insurer declined, cancelled or non-renewed cyber insurance for the Applicant? (Missouri applicants: do not answer)

Yes

Declined / cancelled / non-renewed: details

Governance Controls

Are you subject to any Regulations – Biometric Data Law, GDPR, CCPA or HIPAA?

Yes

If yes, are you compliant including protocols to prevent the wrongful collection of Private Information?

Yes

Does your organization have a Written Information Security Policy (WISP) and/or Privacy Policy?

Yes

Vendor Risk Management Protocols - Cyber Risk Controls and Contractual Language?

Yes

Is the Applicant compliant with Payment Card Industry Data Security Standards (PCI-DSS)?

N/A

Yes

Do you have an employee-training program relating to Cyber Risk, including Phishing?

Yes

Security Controls

How many network capable endpoints (computers or mobile devices) does the Applicant have in their care, custody or control?

Please enter a number greater than or equal to 0.

What is the approximate total dollar value of the computer system? ($)

Please enter a number greater than or equal to 0.

Do you have Firewalls?

Yes

Do you have Anti-Virus – Static or Heuristic?

Yes

Encryption tools on Private Information – At Rest, In-Transit and/or Mobile Devices?

Yes

If possible, please provide some information around your encryption policy/procedure (Optional):

End-Point Detection/Response (EDR) or Intrusion Detection/Prevention (IDR) Tool?

Yes

Conduct Vulnerability Scanning and Patching for all platforms or applications?

Yes

If yes, how often

15. Do you have Multi-Factor Authentication enforced on the following platforms:

15a. MFA - Privileged User Accounts

Yes

15b. MFA - Remote Access – Remote Desktop, Virtual Private Network, Virtual Desktop Infrastructure

Yes

15c. MFA - Email, including Office 365, G-Suite or other provider

Yes

15d. MFA - Critical platforms or applications to operate the business

Yes

15e. MFA - Critical platforms or applications that handle Private Information

Yes

15f. MFA - Backups or Recovery

Yes

Do you have an email filtering tool including the ability to pre-screen, external source identification, attachments and links evaluation, quarantine, sandbox or automatic detonation of malicious emails?

Yes

Do you take regular backups of all organizational critical platforms, applications or information?

Yes

17a. Are the backups encrypted?

Yes

17b. Is recovery of critical platforms, applications or information from backups documented?

Yes

17c. Are backups stored in a secure location (separate from network or system)?

Yes

17d. How frequently is data backed up?

17e. How often is the recovery from backups being tested?

17f. Recovery Time Objective (RTO) to restore from backups?

Do you have plans in place for Incident Response, Business Continuity and Disaster Recovery?

Yes

If one or more of these plans are in place, have they been tested?

Yes

Does the Applicant use any end-of-life (no longer supported) software or hardware?

Yes

Is Remote Desktop Protocol (RDP) open to the internet?

Yes

Does the Applicant use a managed service provider (MSP) for IT?

Yes

MSP name

Media Content Controls

Does the Applicant publish or distribute content/material (website, social media, marketing, publications)?*

Yes

N/A - No content/material published

Choose N/A to skip the rest of this section.

Content Review Process – Review Content/Material being disseminated prior to release?

Yes

Does the Applicant obtain proper licensing for Content/Material?

Yes

Does the Applicant have procedures in place to remove controversial Content/Material?

Yes

Cyber Crime Controls

Are all wire transfers subject to a three step process: (a) initiation (b) approval and (c) release?

Yes

If yes, are the steps completed by two or more authorized individuals?

Yes

Is a callback or alternative notification process in place for all electronic transfers of funds?

Yes

Do you train your employees concerning the detection of Business Email Compromise (BEC)?

Yes

Declaration and Signature

During the past five (5) years, has the Applicant experienced any incidents, occurrences, Claims or Losses related to (i) a Network Security Breach, (ii) a Privacy Violation or (iii) a Privacy Threat or Security Threat stemming from the Applicant or does the Applicant have knowledge of a situation or circumstance which might otherwise result in a Claim against the Applicant with regard to issues related to the Insurance sought?*

Yes

Please give complete details

Attachments (optional)

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, xls, xlsx, Max. file size: 10 MB, Max. files: 10.

Additional comments

The undersigned, an authorized principal, partner or officer of the Applicant, declares that the statements in this application and any attachments are true and complete to the best of his or her knowledge after reasonable inquiry. If any information changes before the policy effective date, the Applicant will promptly notify us, and any quote or binder may be changed or withdrawn. Signing this application does not bind the Applicant or any insurer to complete the insurance, but if a policy is issued, the insurer will rely on this application and it will become part of the policy. The Applicant authorizes this information to be shared with insurance companies for the purpose of obtaining quotes.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false, incomplete or misleading information, or conceals for the purpose of misleading any fact material thereto, commits a fraudulent insurance act, which is a crime and may subject the person to criminal and civil penalties, including fines, imprisonment and denial of benefits. Additional state-specific fraud notices may apply and will be provided by the insurer where required.

Applicant statement*

I have read the declaration and fraud warning above and agree to them.

Name (Please Print)*

Title (Must be Principal, Partner, or Officer)*

Signature*

Your Name
Your Name
Your Name

Date*

How did you hear about us?

Cyber Liability Application

NOTICE

General Information

Governance Controls

Security Controls

Media Content Controls

Cyber Crime Controls

Declaration and Signature

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