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Cyber Liability and Data Security + (RT Specialty)

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Cyber Liability and Data Security +
Cyber APP 5/13
page 1 of 4
This is an application for a policy which includes Claims Made coverage. Please read your policy carefully. Defense costs shall be applied
against the retention.
Name of applicant: _________________________________________________________ DBA: ________________________________
Location address: _________________________________________________________________________ Same as mailing address
City: ______________________________________________________________ State: ________ Zip:________________________
_
Web address: _____________________________E-mail address of primary contact: __________________________________________
Description of operations: __________________________________________________________________________________________
Annual Revenue for most recent 12-month period_______________________________ Number of Employees____________________
Subsidiaries for which coverage is sought ________________________________________________________ % owned_____________
Current cyber or data breach coverage (provide insurer name, coverage, limits, retroactive date, premium) __________________________
_______________________________________________________________________________________________________________
Is the applicant affiliated with a franchise? Yes No
Personal Information means non-public personal information about an individual, including but not limited to any one of the following;
electronic medical record, social security number, financial or bank account information, drivers license number or identification card number,
full credit card number and other non-public information protected under Federal and/or state privacy laws and regulations with respect to
individuals..
GENERAL INFORMATION:
1. Does the applicant or a third party service provider on behalf of the applicant, store (non-employee) Personal Information? Yes No
If “Yes”, complete a. - d. below. Each answer should include total information stored or held by the applicant
and any third party service provider on their behalf.
a. Number of (non-employee) individuals whose Personal Information is stored? ____________________________________________
b. Describe (non-employee) Personal Information that is stored: _________________________________________________________
___________________________________________________________________________________________________________
c. Percentage of (non-employee) Personal Information stored or held that includes medical or
financial information (other than credit card information)? ___________________________________________________________ %
d. Does stored or held (non-employee) Personal Information include complete Social Security numbers or
complete credit card numbers? Yes No
2. Are the following security measures in place for the applicant and any third party service provider the
applicant uses to outsource any part of the applicant’s network/computer system:
a. Anti-Virus software implemented and regularly updated? Yes No
b. Firewall regularly updated for all internet accessible devices & systems and a web application firewall
(WAF) for any web site? Yes No
c. Encryption of stored (non-employee) Personal Information? Yes No
d. Does the applicant store or transfer employee or third party Personal Information on mobile Yes No
devices (including laptops, PDA’s, DVD’s, USB or other portable storage devices)?
If “Yes”, is the Personal Information on such mobile device(s) encrypted? Yes No
e. Security policy and security awareness training with employees on handling Personal Information? Yes No
f. Describe any other security measures the applicant takes to protect Personal Information: _________________________________
__________________________________________________________________________________________________________
DEBIT/CREDIT CARD TRANSACTIONS
3. How many debit/credit card transactions were processed by the applicant over the last 12 months
via Point of Sale (POS) machine? _________________________________________________________________________________
If “0”, skip 3.a. and b below
a. Is the applicant compliant with Payment Card Industry Data Security Standards (PCI DSS)? Yes No
If “no”, explain ______________________________________________________________________________________________
b. Does the applicant change vendor supplied default/administrative passwords for POS systems
and other internet-facing devices as a security measure? Yes No
4. How many debit/credit card transactions were processed over the last 12 months via the applicant’s website? ____________________
If 0, skip 4.a. and 4. b.
a. Does the applicant utilize a checkout or payment page hosted by a third party service provider to
securely process customer payment information outside of the applicant’s business network? Yes No
If yes, has the applicant verified the third party provider is compliant with PCI DSS? Yes No
b. Is the applicant’s website SSL (Secure Sockets Layer) / TSL (Transport Layer Security) protected? Yes No
USLI.COM
USLI.COM
888-523-5545
888-523-5545
Submit Application
WEBSITE ACTIVITY: Does the applicant have a website? Yes No
Answer #5 & 6 only if applicant has a website.
5. Does the applicant regularly verify the material they post on their website or social network(s) is free of privacy
violations, libelous/slanderous content and intellectual property infringements? Yes No
6. Does the applicant provide the ability for others to post comments or content online? Yes No
If yes, answer 6a below:
a. Does the applicant edit postings by third parties in any manner Yes No
If yes, explain: _______________________________________________________________________________________________
7. Does the Applicant agree to maintain commercial general liability insurance? Yes No
If “no” provide a reason. _________________________________________________________________________________________
8. Has the applicant ever had a data breach? Yes No
If “yes”, provide details: _________________________________________________________________________________________
Claim Activity
9. In the last five years, has the applicant received notice of any kind or has any legally required notification
letter been sent or has a claim, suit, inquiry, complaint, notice of charge, notice of hearing, regulatory action,
governmental action or administrative action related to the coverage applied for, including but not limited to
actions involving (1) misappropriation or public disclosure of personal information, (2) libel or slander, (3) privacy
rights, (4) plagiarism, (5) piracy, (6) misappropriation of ideas, or (7) infringement of copyright, domain name,
trademark, logo been made or brought against any person or entity proposed for this insurance? Yes No
If “yes” provide a statement of details. ______________________________________________________________________________
____________________________________________________________________________________________________________
10.
Is the applicant, president, member of the board of directors, executive officer, general counsel, staff attorney,
chief information officer, chief security officer, chief privacy officer, manager or any individual in a substantially
similar position as those previously referenced or with substantially similar responsibilities as those referenced
aware of any allegation, fact, circumstance, contention, incident, threat or situation which may result in a claim,
suit, inquiry, complaint, notice of charge, notice of hearing, regulatory action, governmental action or
administrative action related to the coverage applied for including but not limited to one or more of the actions
described in Question 9, above? Yes No
If “yes” provide a statement of details. _____________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
F
RAUD STATEMENTS
Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if
the misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk,
or to the hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy
in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made
known to the insurer as required either by the application for the policy or otherwise.
Colorado Fraud Statement: 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.
District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
Florida Fraud Statement: 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 of the third degree.
Florida Notice: (Applies only if policy is non-admitted) You are agreeing to place coverage in the surplus lines market. Superior coverage
may be available in the admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida
Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the
admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida
and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously
assessed punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this
Application and such Policy provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in
the State of Florida and Illinois is limited to “vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive
damages.
Kansas Fraud Statement: 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 statement as part
page 2 of 4Cyber APP 5/13
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 may be guilty of a crime and may be subject to fines and confinement in prison.
Kentucky Fraud Statement: 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.
Maine Fraud Statement: 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. A binder may not be
withdrawn but a prospective notice of cancellation may be sent and coverage denied for fraud or material misrepresentation in obtaining
coverage. A policy may not be unilaterally rescinded or voided.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information
contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any
statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in
effect for less than 90 days or is being canceled for nonpayment of premium.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents,
occurrences or alleged Wrongful Acts or Wrongful Employment Acts that took place prior to retroactive date, if any, stated on the declarations.
This policy shall cover only those claims made against an insured while the policy remains in effect for incidents reported during the Policy
Period or any subsequent renewal of this Policy or any extended reporting period and all coverage under the policy ceases upon termination
of the policy except for the automatic extended reporting period coverage unless the insured purchases additional extend reporting period
coverage. The policy includes an automatic 60 day extended claims reporting period following the termination of this policy. The Insured may
purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36 months following the termination of
this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several years of a claims-
made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium
increases independent overall rate increases until the claims-made relationship has matured.
North Dakota Fraud Statement: Notice to North Dakota applicants – Any person who knowingly and with the intent to defraud and 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 also be
subject to a civil penalty.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Ohio Notice: By acceptance of this policy, the Insured agrees the statements in the application (new or renewal) submitted to the company
are true and correct. It is understood and agreed that, to the extent permitted by law, the Company reserves the right to rescind this policy, or
any coverage provided herein, for material misrepresentations made by the Insured. It is understood and agreed that the statements made in
the insurance applications are incorporated into, and shall form part of, this policy. I understand that any material misrepresentation or omission
made by me on this application may act to render any contract of insurance null and without effect or provide the company the right to rescind
it.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon Fraud Statement: Notice to Oregon applicants: Any person who, with intent to defraud or knowing that he is facilitation a fraud against
an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud.
Pennsylvania Fraud Statement: 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.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive
Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which
allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional
location(s) of the Named Insured, outside the state of Utah, for which coverage is sought under the same policy.
Vermont Fraud Statement: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance may be subject to fines and confinement in prison.
Virginia Notice: This Policy is written on a claims-made basis. Please read the policy carefully to understand your coverage. You have
an option to purchase a separate limit of liability for the extended reporting period. If you do not elect this option, the limit of liability for the
extended reporting period shall be part of the and not in addition to limit specified in the declarations. If you have any questions regarding the
cost of an extended reporting period, please contact your insurance company or your insurance agent. Statements in the application shall be
deemed the insured’s representations. A statement made in the application or in any affidavit made before or after a loss under
the policy will
not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.
Virginia Fraud Statement: Any person who knowingly and with intent to defraud an insurer, submits an Application for insurance or files a
claim containing a false or deceptive statement is guilty of insurance fraud.
Utah Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Washington Fraud Statement: 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.
page 3 of 4
Cyber APP 5/13
page 4 of 4
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.
Retail agency name: _______________________________________________ License#: __________________________________
Agent’s signature: __________________________________________Main agency phone number ___________________________
(Required in New Hampshire)
Agency mailing address: _______________________________________________________________________________________
City: _______________________________State: _________________________ Zip: ______________________
The undersigned represents that to the best of his/her knowledge and belief the particulars and statements set forth herein are true and agrees
that those particulars and statements are material to acceptance of the risk assumed by the Company. The undersigned further declares that
any changes to the information contained in this application prior to the effective date of the insurance applied for which may render inaccurate,
untrue, or incomplete any statement made will immediately be reported in writing to the Company and the Company may withdraw or modify
any outstanding quotations and/or authorization or agreement to bind the insurance. The Company is hereby authorized, but not required to
make any investigation and inquiry in connection with the information, statements and disclosures provided in this application. The decision
of the Company not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Company and shall not
stop the Company from relying on any statement in this application. The signing of this application does not bind the undersigned to purchase
the insurance, nor does the review of this application bind the Company to issue a policy. It is understood the Company is relying on this
application in the event the Policy is issued. It is agreed that this Application, including any material submitted there with, shall be the basis of
the contract should a policy be issued and it will be attached and become a part of the policy.
New York Fraud Statement: 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 also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
Signature: ________________________________________________________________________________________________________
(Principal, Partner, or Officer of the Firm)
Title: ____________________________________________________________________________________________________________
Date: ____________________________________________________________________________________________________________
Cyber APP 5/13
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Completed 13 December 2020

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