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Cyber Breach Insurance Form

  • * any expense, loss or liability incurred arising from the theft, loss or unauthorized disclosure of personally identifiable information or protected health information data or the unauthorized access or use of your IT network whether insured under an existing/previous insurance policy or uninsured.
  • PII and PCI:

  • Telemarketing specialist; gambling; social media business; political organization; information technology; or telecommunications; data aggregation; Production or digital distribution of adult media content; Growing, marketing or distribution of cannabis products; Cryptocurrency (Bitcoin, etc.) transactions, investments, account management, mining or wallet service; or escrow services.
  • Funds Transfer Controls:

  • I am an authorized representative of (Company Name) and hereby acknowledge that (1) the above security measures are in place and monitored by the afore mentioned Technology Company (2) should these standards fall below the minimums outlined above, We, the Client, will notify the afore mentioned Technology Company in writing immediately.
  • MM slash DD slash YYYY
  • Clear Signature
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  • 5200 Meadows Road
    Suite 150

    Lake Oswego, OR 97035
  • Phone: 503-726-5933
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