PI-CYBN-CLAIM 03/10
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CYBER SECURITY LIABILITY APPLICATION
SUPPLEMENTAL CLAIM INFORMATION
Name of Insurance Company to which Application is made (herein called the “Insurer”)
Submit one form for each claim or incident. If space is insufficient to answer any question completely,
please use the Additional Information page attached to this application.
1. Full name of the Applicant Firm:
2. Full name of the firm which reported the claim (if different from above):
3. Full name of the claimant:
4. Indicate whet
her: Claim/Suit Incident/Potential Claim
5.
Date / Period of alleged error:
6. Date the claim was reported to the insurance carrier:
7. Other parties against which this claim is made:
8. This claim is:
Open Closed
9.
If CLOSED, indicate the date closed:
10. Please complete the following:
If claim is still open:
a. Claimants settlement demand: $
b. Defendant’s offer for settlement: $
c. Insurance company’s loss reserve: $
d. Deductible: $
e. Total loss and expenses paid to date: $
If claim is closed:
a. Loss paid in excess of deductible: $
b. Expenses paid in excess of deductible: $
c. Deductible: $
d. Settlement reached via:
Court judgment Formal mediation/Arbitration proceeding Out of court settlement
Note: If information is not available, please provide a copy of the suit papers.
11. Name of Insurance company:
12. Claim number:
