Cyber Breach Insurance Form

Do you currently have Cyber Coverage?*

Yes
No

If “YES”, Current Limit*

Have you ever had a Cyber Claim?

* 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.

Yes
No

Do you, or any director, officer, employee or other proposed insured have knowledge or information of any fact, circumstance, situation, event or transaction which may give rise to a claim or privacy breach notification under the proposed insurance?*

Yes
No

PII and PCI:

Do you store records containing non-public personal information or protected health information for more than 250,000 individuals (employees, vendors, customers, patients, etc.)?*

Yes
No

Do you comply with PCI Standards and store more than 250,000 credit/debit cards transactions?*

Yes
No

Do you engage in any of the following activities?*

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.

Yes
No

If yes, please identify:*

Funds Transfer Controls:

Are the identities of customers and vendors, as well as any new or changed contact or bank account details, agreed in writing, and confirmed by phone prior to the issuance of any funds transfers?*

Yes
No

Do you require dual authorization for funds transfers greater than $5,000?*

Yes
No

Company Name*

Mailing Address*

Street Address City State / Province / Region ZIP / Postal Code

Business Description*

Business Revenues (last 12 months)*

Website URL*

Number Of Employees*

Company Contact Name*

Contact Email*

Phone*

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.

Company Name*

Print Name*

Date*

Signature*

Email

This field is for validation purposes and should be left unchanged.

Cyber Breach Insurance Form

PII and PCI:

Funds Transfer Controls:

Contact Info

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