Fillable DataBreach QUICK QUALIFIER AND INDICATION QUESTIONNAIRE FOR DATA (Risk Placement Services, Inc.)

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DataBreach QUICK QUALIFIER AND INDICATION QUESTIONNAIRE FOR DATA (Risk Placement Services, Inc.)

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DB-30001 12 11 Page 1 of 1
DataBreach
SM
QUICK QUALIFIER AND INDICATION QUESTIONNAIRE FOR DATA BREACH
AND PRIVACY LIABILITY INSURANCE
This Questionnaire is for a premium estimate only. For a quotation complete Application for Data Breach and Privacy
Liability, Data Breach Loss to Insured and Electronic Media Liability Insurance (MADB 5001). Applications are available at
www.markelcorp.com
.
1. (a) Full Name of Applicant:
(b) Principal busi
ness premise address:
(Street) (County)
(City) (State) (Zip)
(c) Website(s):
2. Describe in de
tail the Applicant’s business operations:
3. Applicant's gr
oss annual revenues:
Total E-Commerce
(i) Estimated annual gross revenues for the coming year: $
$
(ii) For the past twelve (12) m
onth period: $
$
4. Does the App
licant handle sensitive data for any of the following:
Transmit/Receive
Store
(a) Credit Cards/Debit Cards*? [ ] Yes [ ] No..................... [ ] Yes [ ] No
(b) Financial/Banking Information? [ ] Yes [ ] No..................... [ ] Yes [ ] No
(c) Medical Information (PHI)**? [ ] Yes [ ] No..................... [ ] Yes [ ] No
(d) Social Security Numbers or National Identification Numbers? [ ] Yes [ ] No..................... [ ] Yes [ ] No
(e) Other (specify)
[ ] Yes [ ] No..................... [ ] Yes [ ] No
* Approximate number of credit/debit card transactions for the coming year:
** Approximate number of individuals for which PHI is collected, transmitted or stored:
5. Is the Applicant:
(a)
In compliance with all HIPAA/HITECH privacy rules?....................................................................... [ ] Yes [ ] No
(i) If No, anticipated date of compliance?
(b) Certified as being PCI co
mpliant? ..................................................................................................... [ ] Yes [ ] No
(i) If No, anticipated date of compliance?
6 Indicate the number
of sensitive data records the Applicant stores currently:
7. Does the App
licant have a dedicated senior manager responsible for Information Security and Privacy?
................................................................................................................................................................. [ ] Yes [ ] No
8. Does the Applicant allow the use of laptops, mobile devices or other portable media?.......................... [ ] Yes [ ] No
(a) If Yes, does the Applicant ensure all sensitive information is encrypted?....................................... [ ] Yes [ ] No
Signing this Questionnaire does not bind the Company to provide or the applicant to purchase the insurance.
Name of Applicant Title
Si
g
nature of A
pp
licant Date
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DataBreach QUICK QUALIFIER AND INDICATION QUESTIONNAIRE FOR DATA (Risk Placement Services, Inc.)

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Completed 30 July 2020

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