Application Cyber Cyber Liability Application Step 1 of 2 50% Applicant InformationName First Last Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please select your Industry type:Professional Services Firms (except legal)Public Entity (municipalities, counties, ect)Health & Medical (hospitals, private practice)Education, School Districts, colleges, private schoolsHospitality - hotels, restaurantData Process ControlsHigh Traffic websites and blogsSocial Networking SitesDating SitesManufacturingFinancial InstitutionsConstruction FirmsContractorUtility CompanyCont. Please select your Industry type:Government AgencyCharitiesInsurance BrokersInsurance CompaniesReal EstateRetailTelecommunicationsMortgage BrokerGas StationCar DealerPharmacyDomestic ServicesInvestment AdvisorsCPAPlease provide a general description of operations:Number of employees: Please check one of the following regarding your entity type: Public entity Academic entity Other Annual revenue: Population of your municipality or district: (public entity) Total annual enrollments: (if academic) How many electronic records (customer or emplyees) containing personally identifiable information or protected health information are held? Coverage Limit RequestedCheck limit $1,000,000 $2,000,000 $3,000,000 $4,000,000 Have you purchased a previous Cyber Policy? Yes No Retroactive Date on your Current Cyber Policy MM slash DD slash YYYY Risk Controls1. Do you control access to the computer system? Yes No 2. Do you utilize updated firewalls and a virus protection? Yes No 3. Do you outsource any part of the internal networking/computer system or internet access to others? Yes No 4. Do you have an employee responsible for IT security? Yes No 5. Does your hiring process include criminal background checks? Yes No 6. Do you have a written business or corporate-wide privacy policy? Yes No 7. Do you regularly test security or privacy controls? Yes No 8. Have you ever experienced a privacy or data breach? Yes No Please explain:9. Do you allow employees to download personal client informaiton or other confidential information onto laptops or other data files? Yes No Is the data encrypted? Yes No 10. What personal information is held? Social Security Numbers Financial Account Numbers Personal Health Information 10. cont. (check all that apply) Driver's License Numbers Credit Card Numbers Other How many credit card "annual" transactions? Please explain "other"11. Have you ever filed a Privacy/Data Breach claim? Yes No Date MM slash DD slash YYYY $ Amount paid $ Please note the date of incident and provide brief explanation, amount paid, remediation efforts since.12. Do you use encryption tools to enhance the integrity and confidentiality of confidential information? Yes No In which scenario(s) Data at rest (server, computers) Data in transit Data stored on removable media (CDs, backup tapes, USB devices, et.) 13. Do you back up your data at least once per week and store in an off-site location, or their outsourcer does it on your behalf? Yes No 14. Do you have a process to review all the content prior to posting on the applicant's website? Yes No 15. Do you have a procedure for responding to allegations of liebel, slander or infringement of a thrid-party's privacy rights on the applicant's website? Yes No 16. Do you store, proecess or handle credit card transactions, are you compliant with Payment Card Industry Data Security Standards? If yes, at what level? Yes No Credit card process level.17. Are you aware of any release, loss or disclosure of personally identifiable information in your care, custody or control, or anyone holding such information on your behalf in the most recent three -year time period from the date of this application? Yes No 18. Are you aware of any incident that could give rise to a claim under the proposed Insurance? Yes No Please explain the incident(s)Do you understand that we may require additional information after reviewing your application? Yes No Disclosure: Do you hereby agree that by completing this application we are NOT providing insurance coverage. We are only evaluating your information for a quote and will not rely on this application for coverage? Yes No
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