Cyber Liability Insurance | Athena Insurance and Financial Services

If you would like assistance with the completion of this application you can either call us or use a contact form. Phone 209-223-1870 or click here…

1Applicant

2 Revenue

3Eligibility

4Auto

5Property

6Risk

7Loss History

Applicant Information
Name
First Last
Email
Phone
Website
Mail Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please provide a general description of operations:
Indicate percentage of gross receipts. If new in business estimate.
Custom Software Development:
Technical project management:
Packaged software development: (include number of licenses)
Database administration:
Packaged software installation/configuration:
Remote data back-up services:
Data/records imaging, warehousing or storage:
Packaged software and/or hardware sales:
Business intelligence/reporting:
Hardware equipment evaluationa/selection:
Records management/retrieval:
Application service provider:
Hardware manufacturing:
System/network evaluation:
Hardware maintenance services:
Network architecture/design:
Telecommunications:
Network/computer security:
Webhosting re-selling a third party's hosting services:
Network/cabling/wiring:
Webhosting on your own servers:
Network/computer/application support:
Wireless Installation/configuration:
Co-location services:
Systems optimization:
Internet service provider:
Help desk/Call center:
Social networking:
IT staffing:
Home theater installation:
Consulting (describe in desctiption)
Video production, editing, animation:
Web site design/development
Online publishing:
Search engine optimization:
Web search engines:
Graphic design:
Online databases:
Training and education:
Online sales auctions:
Other Services not listed:
Web hosting on your own servers:
Revenue
Annual sales generated from work performed within the U.S. territories and Canada:
Annual sales generated from work performed outside the U.S., its territories and Canada:
Total annual / project sales within the U.S. & Canada and outside of U.S. & Canada:
Who is providing the services? Head count
Principals, partner, officers
+ not providing services:
= Total principals:
Employees Full time:
+ part-time:
= Total employees:
Independent Contractors):
+ all other types
= Total Indept. Contractors:
Prior Insurance
What is the earliest date of continuous error and omissions liability coverage?
MM slash DD slash YYYY
- Unknown
- No prior coverage

Eligibility Criteria
1. Please indicate as a percentage your services that affect or enable any of the following:
- None
1a. Fund transters, financial transactions, equity trading or loan fulfillment:
Please enter a number from .01 to 1.00.
1b. Video game development (provide title and style of games:
Please enter a number from .01 to 1.00.
1c. Lottery, sweepstakes, gaming, online casino or other games of chance:
Please enter a number from .01 to 1.00.
1d. Firmware or embedded software:
Please enter a number from .01 to 1.00.
1e. Mechanical, electrical, chemical, civil or architectural design or engineering:
Please enter a number from .01 to 1.00.
1f. Robotics or process control of industrial or monitoring (including but not limited to burglar/fire alarms and camera systems):
Please enter a number from .01 to 1.00.
1g. Physical security system installation or monitoring (including but not limited to burglar/fire alarms and camera systems):
Please enter a number from .01 to 1.00.
1h. Global Positioning Systems (GPS), Geographic Information Systems (GIS), navigation systems development, maintenance or support:
Please enter a number from .01 to 1.00.
1i. Aircraft, air-ground equipment, military defense and/or weaponry of any kind including classified information:
Please enter a number from .01 to 1.00.
1j. Medical, dental or healthcare diagnosis, monitoring or treatment including electronic medical records:
Please enter a number from .01 to 1.00.
1k. Pharmaceutical formulaitons, production or prescriptions including clinical data:
Please enter a number from .01 to 1.00.
1l. 911 or other emergency response and/or dispatch:
Please enter a number from .01 to 1.00.
1m. Energy, power plant, utility or pollution monitoring, supply or distribution:
Please enter a number from .01 to 1.00.
Total should equal 100%
Please explain government compliance services:
2. Does the applicant provide government regulations compliance services?
- Yes
- No

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Application Cyber liability Consultants and more

Applicant Information

Indicate percentage of gross receipts. If new in business estimate.

Revenue

Who is providing the services? Head count

Prior Insurance

Eligibility Criteria

Hired and Non-owned Auto Liability

Property Information

Risk Controls

Loss Information

Additional Insureds/Waiver of Transfer of Rights of Recovery/Primary & Non-Contributory

Additional Applicant Information

Prior Insurance History

Disclosure Notice

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