Cyber Liability

General Information

Applicant Name *

Applicant Contact Name *

Applicant Contact Title *

Physical Address *

Physical Address Line 2

City *

State *

Zip *

Mailing address is same as billing address

Mailing address is same as billing address

Mailing Address

Mailing Address Line 2

City

State

Zip

Email Address *

Website

Phone Number *

Include extension, if applicable

Fax Number

Officers & Owners

Officer/Owner Block

1	Name * Age Title Ownership % * Active in Daily Business? Yes No
1	Name * Age Title Ownership % * Active in Daily Business? Yes No

Add Officer/Owner

Total Ownership %

Revenues

12-month Gross Revenues *

Your retained commission after paying underwriters plus revenue/fees from closing, escrow, or title searches.

Cyber Threat Protection

Any “No” responses will require an explanation.

Is data backed up on a regular basis? *

Yes No

Explain your "No" Response *

Are anti-virus and firewall systems in place and updated on a regular basis (at least quarterly)? *

Yes No

Explain your "No" Response *

Are mandatory individual, unique, non-trivial IDs and passwords utilized for all devices? *

Yes No

Explain your "No" Response *

Are all laptops, computers, and mobile devices storing Personally Identifiable Information (PII) encrypted? *

Yes No

Explain your "No" Response *

Can you confirm that the applicant does not accept any credit card transactions which are not processed by a payment processor? *

Yes No

Explain your "No" Response *

Are the number of unique PII / Personal Health Information records less than 500,000 (1,000,000 if revenues are in excess of $5,000,000) *

Yes No

Explain your "No" Response *

Can you confirm that the applicant has not sustained a system intrusion, tampering, virus, or malicious code attack, loss of data, hacking incident, data theft, or similar incident within the past 5 years? *

Yes No

Explain your "No" Response *

Can you confirm that no person has alleged that their confidential information has been compromised? *

Yes No

Explain your "No" Response *

Can you confirm that the applicant has not sustained any unscheduled network outage or interruption in the past 24 months, except where the outage has been caused by natural events (storms, tornadoes, etc.)? *

Yes No

Explain your "No" Response *

Can you confirm that the applicant has not experienced any claims or losses, or are aware of any circumstances that could give rise to a claim or loss that may have been covered by this policy? *

Yes No

Explain your "No" Response *

Cyber Application

General Information

Officers & Owners

Revenues

Cyber Threat Protection

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