INSURANCE AGENT - CYBER LIABILITY COVERAGE INDICATION REQUEST FORM
 
 
 
This Cyber Liability entity coverage is designed for:
  • Agents in NY, VT and U.S. territories
 
 
 
 
 
 
 
 
I. Applicant Details
 
 
 
 
Entity Name
 
 
 
 
Address*
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Website*
 
 
Year Established*
 
 
 
Contact Person (First and Last Name)*
 
 
 
Contact's Phone (xxx) xxx-xxxx*
 
 
Contact's Email*
 
 
 
 
 
 
Applicant's Operations (% of Business i.e. Life, Health, P&C, etc.)*
 
 
 
 
 
 
Personally Identifiable Information Held:
 
Social Security Numbers
 
 
Credit Card Information
 
 
 
Employee Information
 
 
Personal Health Data
 
 
 
Bank Account Information
 
 
Other
 
 
 
If Other, please specify
 
 
 
 
 
 
Number of records maintained by the Applicant containing the above information (approx.):*
 
 
 
**(if >20,000, enter estimated number of PII records maintained here)
 
 
 
 
 
 
Gross Commissions Past Year*
 
 
 
Gross Commissions Current Year*
 
 
 
Gross Commissions Next Year (est.)*
 
 
 
 
 
 
II. Statement of Fact for Cyber & Privacy Liability Coverage
 
 
 
 
Do you and your subsidiaries comply with the requirements detailed in the Statement of Fact below?*
 
Yes
No
 
 
  1. You have anti-virus software installed and enabled on all desktops, laptops and servers (excluding database servers) and it is updated on a regular basis.
  2. You have firewalls installed on all external gateways.
  3. You take regular back-ups (at least weekly) of all critical data and store the same offsite or in a fire-proof safe, or your outsourced service provider meets this requirement.
 
 
 
 
 
If you store medical records or Protected Health Information (PHI), do you comply with the following?*
 
 
 
  1. You have conducted a review of the business to ensure compliance with all relevant HIPAA legislation.
  2. You ensure that all PHI transmitted over open networks and/or stored on portable devices is encrypted.
 
 
 
 
 
If you process or store credit card information (where this is not outsourced to a third party that accepts full responsibility for PCI compliance), do you comply with the following?*
 
 
 
  1. You have been certified as being PCI compliant within the last 12 months, or have successfully completed a self-assessment audit.
 
 
 
 
 
III. Claims Information
 
 
 
 
In regards to claims or circumstances that could give rise to a claim, are the below statements true?*
 
Yes
No
 
 
  1. After full inquiry, you are not aware of any circumstances, complaints, claims, loss, penalties or fines levied against you in the last five years, in relation to the risks that this application relates to.
  2. You are not aware of any circumstances or complaints against you in relation to data protection or security, or any actual security violations or security breaches either currently or in the past five years.