CYBER LIABILITY APPLICATION
 
 
 
This Cyber Liability entity coverage is designed for:
  • Insurance Agencies with Multiple Producers
  • Life & Health Agents
  • Registered Reps
  • Investment Advisors and Financial Planners
  • Property & Casualty Agents
  • Real Estate Agents
 
 
 
 
 
Client Information
 
 
 
 
Company Name*
 
 
 
 
Address
 
 
City
 
 
 
State
 
 
ZIP Code
 
 
 
Applicant's Email*
 
 
Applicant's Phone*
 
 
 
 
 
 
Applicant Information
 
 
 
 
Gross Annual Income
 
 
 
 
 
 
 
Does applicant back up data at least once a week and store in an offsite location or their outsourcer does so? i.e. Is there a secure place, not on the Insured's property, that their information is backed up to, such as a third party storage site?
 
Yes
No
 
 
 
 
 
 
Does the applicant have antivirus and firewalls in place and are these regularly updated (at least quarterly)? i.e. Does the Insured have an antivirus system, such as McAfee or Norton Antivirus or AVG protecting their computer systems?
 
Yes
No
 
 
 
 
 
 
Has the applicant previously purchased a Cyber Policy?
 
Yes
No
 
 
 
If Yes, please include coverage retroactive date (XX/XX/XXXX)
 
 
Current Cyber Insurance Broker
 
 
 
 
 
 
Is the applicant aware of or have any grounds for suspecting any circumstances which might give rise to a claim?
 
Yes
No
 
 
 
 
 
 
Within the last 5 years, has the applicant suffered any systems intrusions, tampering, virus or malicious code attack, loss of data/portable media, hacking incident, extortion attempts or data theft resulting in a claim that this insurance would cover?
 
Yes
No
 
 
 
 
 
 
Are you interested in Optional Cyber Deception Coverage?
 
Yes
No
 
 
 
Cyber Deception extension provides coverage for the intentional misleading of the Applicant by means of a dishonest misrepresentation of a material fact contained or conveyed within an electronic or telephonic communication(s) and which is relied upon by the Applicant believing it to be genuine. This is commonly known as "spear-phishing" or "social engineering". Please note that the Cyber Deception Coverage ONLY applies to Money or Goods of the Insured and will NOT apply to Money or Goods of a Third Party (Customer) held in their Care Custody and Control and released to others.