© 2014 Risk Placement Services, Inc. V2.0 10/14
CYBER LIABILITY PREMIUM INDICATION FORM
(Completion of this form does not guarantee a contract of insurance. This is for a non-binding premium indication
only. Premiums are subject to change and may require completion of a full cyber liability application.)
APPLICANT INFORMATION
Name of applicant: _________________________________________________________________________________________
Address of applicant: _______________________________________________________________________________________
City: ___________________ State: ________ Zip: _______ Phone: ______________ URL: ____________________________
General description of operations of applicant:
_________________________________________________________________________________________________________
Number of employees: ______________ Annual revenue: ________________
Population (if public entity): __________ Total annual enrollment (if academic): _____________
How many electronic records (customers or employees) containing personally identifiable information (PII) or protected
health information (PHI) are held by the applicant? ________________________________
1. Does the applicant control access to the computer system? Yes No
2. Does the applicant utilize updated firewalls and a virus protection? Yes No
3. Does the applicant outsource any part of the internal networking/computer
system or internet access to others? Yes No
4. Does the applicant have an employee responsible for IT security? Yes No
5. Does the applicant’s hiring process include criminal background checks? Yes No
6. Does the applicant have a written corporate-wide privacy policy? Yes No
7. D
oes the applicant regularly test their security or privacy controls? Yes No
8. Has the applicant ever experienced a privacy or data breach? (if Yes, explain) Yes No
9. Does the applicant allow employees to download personal client information
or other confidential information onto laptops or other data files? Yes No
(If yes, is the data encrypted?) Yes No
10. What personal client or employee information is held? (Check all that apply)
Social Security Numbers Driver’s License Numbers
Financial Account Numbers Credit Card Numbers (if checked, # of annual transactions: ________ )
Personal Health Information Other (please specify) _________________________
11. Has the applicant ever filed a Privacy/Data Breach claim? Yes No
(If “yes”, please note date of incident and provide brief explanation, amount paid, remediation efforts since, etc.)
_____________________________________________________________________________________________
12. Does the applicant use encryption tools to enhance the integrity and confidentiality of confidential information?
If “Yes”, in which scenario is the data encrypted? (Check all that apply)
Data at rest (servers, computers) Data stored on removable media (CDs, backup tapes, USB devices, etc.)
Data in transit
13. Does the applicant back up their data at least once per week and store in an off-site location, or their
outsourcer does on their behalf? Yes No
14. Does the applicant have a process to review all content prior to posting on the applicant’s website? Yes No
15. Does the applicant have a procedure for responding to allegations of libel, slander or infringement of
a third-party’s privacy rights on the applicant’s website? Yes No
16. If applicant stores, processes or handles credit card transactions, is the applicant compliant with
Payment Card Industry Data Security Standards (PCI DSS)? (If “Yes”, at what level: ____ ) Yes No
17. Is applicant aware of any release, loss or disclosure of personally identifiable information in its
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. Is applicant aware of any incident that could give rise to a claim under the proposed insurance? Yes No
(If “Yes”, please explain ) ____________________________________________________________________
_________________________________________________________________________________________
I understand that this is a non-binding premium indication for coverage. To receive a bindable quote, I/my client may be required to complete a full
Cyber Liability application.
Applicant or Agent Signature: _____________________________________ Date: _________________
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