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Cyber Liability Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

General Information
First Name
Required
Last Name
Required
Position
Required
E-Mail Address
Required
Name of Business
Required
Website Address
Optional
Primary Phone Number
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Annual gross revenue/turnover
Required
Last fully completed financial year
Required
Approximately how many PII’s are retained within your computer network, databases and records?
Required
PII is defined as a personally identifiable record on an individual that can be used to identify, contact or locate a single individual.
Identify the type of PII retained on your network
Payment card data
Required

Healthcare Data
Required

Other PII
Required

If yes to any, please provider details of the nature of this PII
Optional
Network Information
Do you have a business continuity plan in force to avoid business interruption due to systems failure?
Required

Are all portable and mobile devices encrypted?
Required

If no, please detail the type and how much PII is stored on portable media devices and how it is protected in the absence of encrpytion
Optional
Do you have firewalls and automatically updating antivirus software in force across your network?
Required

Is all sensitive and confidential information stored on your databases, servers and data files encrypted?
Required

Is all information held in a physical form disposed of or recycled by confidential and secure methods?
Required

Do you have a privacy policy on your website which has been legally reviewed and includes a statement advising users as to how any information collected will be used and for what purposes?
Required

Do you have a process in force to obtain a legal review of all media content and advertising materials prior to release?
Required

Historical Information
During the last three years have you:
Sustained any unscheduled or unintentional network outage, intrusion, corruption or loss of data?
Required

Received notice or become aware of any privacy violations or that any data or personally identifiable information has become compromised?
Required

Been subject to any disciplinary action, regulatory action, or investigation by any governmental, regulatory or administrative agency?
Required

Received any injunction(s), lawsuit(s), fine(s), penalty(s) or sanction(s)?
Required

Become aware of any circumstance or incident that could be reasonably anticipated to give rise to a claim against the type of insurance(s) being requested in this application?
Required

If ‘Yes’ to any questions within this section, please provide full details:
Optional
How did you hear about us?
Optional
Submission Validation
Required
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
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