Fillable CYBER SECURITY LIABILITY RENEWAL APPLICATION (Philadelphia Insurance Companies)

Fill Online, Printable, Fillable, Blank CYBER SECURITY LIABILITY RENEWAL APPLICATION (Philadelphia Insurance Companies) Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

CYBER SECURITY LIABILITY RENEWAL APPLICATION (Philadelphia Insurance Companies)

On average this form takes 50 minutes to complete

The CYBER SECURITY LIABILITY RENEWAL APPLICATION (Philadelphia Insurance Companies) form is 6 pages long and contains:

  • 0 signatures
  • 67 check-boxes
  • 170 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CYBER SECURITY LIABILITY RENEWAL APPLICATION
COVERAGES E., F., AND G. ARE CLAIMS MADE AND REPORTED COVERAGES.
CLAIM
EXPENSES UNDER COVERAGES E., F., AND G. ARE INCLUDED WITHIN THE AVAILABLE LIMIT OF
INSURANCE. ANY CLAIM EXPENSES PAID UNDER THIS COVERAGE FORM WILL REDUCE THE
AVAILABLE LIMITS OF INSURANCE AND MAY EXHAUST THEM COMPLETELY. PLEASE READ THE
ENTIRE POLICY CAREFULLY.
Certain terms have specific meaning as defined in the policy form and noted in bold. Throughout this Application
the words "you" and "your" refer to the Named Insured shown in the Declarations, and any other person or
organization qualifying as a Named Insured under the proposed policy.
SECTION I – GENERAL INFORMATION
Name of Applicant:
Address:
City:
State:
Zip:
Telephone:
Website: www.
Risk Management Contact:
Risk Manager Email:
Please provide a brief description of operations:
Please list all subsidiaries for which coverage is requested under this policy:
To enter more information, please use the Additional information page attached to this application.
Other Countries
Total
Total number of employees
Annual sales or revenue
$
$
Annual revenue from online sales
or services
$
$
1.
Do you collect, store or process any of the following types of Personally Identifiable
Information (PII)?
Yes
No
Please check all that apply:
Bank Account Information
Protected Health Information / Medical Records
Credit Card Numbers
Social Security Numbers
Driver’s License Information
Other: (please specify)
2.
Please estimate the total number of Personally Identifiable Information records held:
PI-CYB-021 05/17
Page 1 of 6
© 2017 Philadelphia Consolidated Holding Corp.
11/2017
Clear Application
Print Application
SECTION II - COVERAGE SELECTION (If no changes are requested, leave blank)
Insuring Agreement
Requested Limit
Requested Deductible
A.
Loss of Digital Assets
$
$
B.
Non-Physical Business Interruption & Extra Expense
$
(N/A – Time Retention Applies)
C.
Cyber Extortion Threat
$
$
D.
Security Event Costs
$
$
E.
Network Security & Privacy Liability
$
$
F.
Employee Privacy Liability
$
$
G.
Electronic Media Liability
$
$
H.
Cyber Terrorism Coverage
$
$
SECTION III - LOSS EXPERIENCE
(Explain any “Yes” responses, including corrective actions and damages incurred
on the ADDITIONAL INFORMATION page below):
1.
Since you last completed an application for the proposed insurance, have you sustained
any losses due to unauthorized access, unauthorized use, virus, denial of service attack,
electronic media liability, data breach, data theft, fraud, electronic vandalism, sabotage or
other similar electronic security events?
Yes
No
2.
Since you last completed an application for the proposed insurance, have you experienced
any network related business interruption exceeding eight (8) hours other than planned
maintenance?
Yes
No
3.
Since you last completed an application for the proposed insurance, has anyone alleged
that you were responsible for damage to their computer system(s) arising out of the
operation of your computer system(s)?
Yes
No
4.
Since you last completed an application for the proposed insurance, have you received a
complaint or other proceeding (including an injunction or other request for non-monetary
relief) arising out of intellectual property infringement, copyright infringement, media
content, or advertising material?
Yes
No
5.
Since you last completed an application for the proposed insurance, has anyone made a
demand, claim, complaint, or filed a lawsuit against you alleging invasion of, or interference
with rights of privacy, or the inappropriate disclosure of personally identifiable information
(PII)?
Yes
No
6.
Since you last completed an application for the proposed insurance, have you been the
subject of an investigation or action by any regulatory or administrative agency for privacy-
related violations?
Yes
No
SECTION IV – RISK CONTROLS
1.
Do you have a firewall?
Yes
No
a.
How often do you review the rules within the firewalls?
b.
When was the last time a rule was removed / deactivated?
2.
Do you require your lnformation Technology Department or outsourced third party
vendors/providers to adhere to a software update process, including software patches and
anti-virus software definition upgrades?
Yes
No
3.
Do you perform virus scans of emails, downloads, and portable devices?
Yes
No
4.
Do you restrict access to sensitive client, customer, employee or other third party
information?
Yes
No
5. Do you have a process for managing user accounts, including the timely revocation of
access for terminated employees and the removal of outdated accounts?
Yes No
PI-CYB-021 05/17
Page 2 of 6
© 2017 Philadelphia Consolidated Holding Corp.
11/2017
Clear Application
Print Application
6.
Do you have physical security controls in place to restrict access to your computer systems
and sensitive paper records?
Yes
No
7.
Do you have role-based controls or other procedures that address user access to critical
and sensitive computer systems, applications, or records?
Yes
No
8.
Do you have a written business continuity/disaster recovery plan that includes procedures
to be followed in the event of a disruptive computer or network incident?
Yes
No
9.
Are system back-up and recovery procedures tested for all mission-critical systems and
performed at least annually?
Yes
No
10.
Do you have a designated individual or group responsible for information security and
compliance operations? Please specify below by checking all that apply:
Risk Management Department
Chief Information Officer / Chief Information Security Officer
Other: (please specify)
11.
Is all sensitive customer, client and employee data:
a.
encrypted at rest?
Yes
No
b.
encrypted in transit?
Yes
No
c.
accessible via mobile devices, laptops or other portable storage media?
Yes
No
If yes, are the mobile devices, laptops or other storage media encrypted?
Yes
No
12.
How long would it take to restore your operations after a computer attack or other
loss/corruption of data? 0-12 Hours 12-24 Hours 24 Hours
13.
Are mission-critical transactions and security logs reviewed periodically for suspicious
activity?
Yes
No
If yes, how frequently?
14.
Have you undergone an information security or privacy compliance evaluation?
Yes
No
If yes, identify who performed the evaluation, the date it was performed, the type of
evaluation, and attach a copy of it.
Were all recommendations implemented and deficiencies corrected?
If no, please explain on the ADDITIONAL INFORMATION page)
Yes No
15.
Do you outsource critical components of your network/computer system or internet
access/presence to others?
Yes
No
If yes, check all that apply and name the service provider for each category:
TECH-RELATED SERVICE
Internet Service Provider
Backup, co-location
and data recovery
Financial Services and
Payment Processing
Other: “cloud”, ASP,
SAAS, Etc.
Comcast
AT & T
ADP
Amazon
Verizon
Mozy
Authorize.net
Microsoft
Time Warner
HP
Blackbaud
Google
AT & T
IBM
BA Merchant Services
Go Daddy
Optimum / Cablevision
Iron Mountain
First Data
IBM
Cox
Rackspace
Fiserv
Media Temple
Century Link
Sunguard
Global Payments
Endurance/Bluehost
Windstream
TierPoint
Heartland
Rackspace
Charter
In House
Metavente
Akamai
Road Runner
Other:
Paymentech
Verizon
Level 3
Paypal
SoftLayer
Other:
Square
HostGator
Stripe
VMWare/Dell/EMC
Verisign
Salesforce
Other:
Other:
PI-CYB-021 05/17
Page 3 of 6
© 2017 Philadelphia Consolidated Holding Corp.
11/2017
Clear Application
Print Application
16.
Do you have a program in place to periodically test your data security controls?
Yes
No
17.
Do you have written contracts in place to enforce your information security policy and
procedures with third party service providers?
Yes
No
18.
Do such contracts contain hold harmless or indemnification clauses in your favor?
Yes
No
19.
Do you audit all vendors and service providers who handle or access your data and require
them to have adequate security protocols?
Yes
No
20.
Do you have a document destruction and retention policy?
Yes
No
21.
Do you monitor your network in real time to detect possible intrusions or abnormalities in
the performance of the system?
Yes
No
SECTION V – PRIVACY CONTROLS
1.
Have you achieved compliance with the following: (check all that apply)
PCIDSS (Payment Card Industry Data Security Standard )
Yes
No
N/A
GLBA (Gramm-Leach-Bliley Act)
Yes
No
N/A
HIPAA (Health Insurance Portability and Accountability Act)
Yes
No
N/A
2.
Does your hiring process include the following for all employees and independent
contractors (check all that apply):
Drug testing
Work history checks
Criminal background checks
Credit history checks
Educational background
Other (specify):
3.
Do you have a current enterprise-wide computer network and information security policy
that applies to employees, independent contractors, and third-party vendors?
Yes
No
If yes, is the information published within the company (e.g. corporate intranet, employee
handbook, etc.)?
Yes
No
4.
Are all employees periodically instructed on their specific job responsibilities with respect to
information security, such as the proper reporting of suspected security incidents?
Yes
No
5.
Do you have a formal written privacy policy?
Yes
No
If yes, has the policy been reviewed and approved by legal counsel?
Yes
No
6.
Are your information systems and supporting business procedures prepared to honor
customer preferences concerning the opt-out of sharing of non-public, personal information
to non-affiliated third parties?
Yes
No
7.
Do you require the transmission of personal customer information such as credit card
numbers, contact information, etc., as part of your internet-based services?
Yes
No
SECTION VI – MEDIA LIABILITY CONTROLS
1.
Do you have a process to review content or materials (including meta tags) before they are
published, broadcasted, distributed, or displayed on your website for the following:
Defamation (Slander or Libel)?
Yes
No
Right to privacy or publicity?
Yes
No
Copyright, trademark or domain name?
Yes
No
2.
Have your products or services been the subject of copyright, patent or trademark
infringement allegations?
Yes
No
3.
Does your organization use social media?
Yes
No
a.
Do you monitor postings?
Yes
No
b.
Are there formal procedures for complaints?
Yes
No
c.
Is content reviewed by legal counsel?
Yes
No
PI-CYB-021 05/17
Page 4 of 6
© 2017 Philadelphia Consolidated Holding Corp.
11/2017
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge
and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this
Application) are true and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information
in this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the
Company may modify or withdraw the quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company.
FRAUD NOTICE STATEMENTS
ANY PERSON
WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE
CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT
MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN
OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON
TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR
EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR FRAUDULENT
CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES
FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR
ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS
SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A
STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY (IN FL, A
PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY
AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION OR STATEMENT
AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL
INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH
SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE
OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS FILES AN
APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A
DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES
AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS
SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________
________________________________________
SIGNATURE DATE
SECTION
TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-CYB-021 05/17
Page 5 of 6
© 2017 Philadelphia Consolidated Holding Corp.
11/2017
Clear Application
Print Application
ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application. Please identify the
question number to which you are referring.
______________________________________________
Signature Date
PI-CYB-021 05/17
Page 6 of 6
© 2017 Philadelphia Consolidated Holding Corp.
11/2017
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

CYBER SECURITY LIABILITY RENEWAL APPLICATION (Philadelphia Insurance Companies)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 29 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document