Fillable Plus Company Agents DataBreach and Brokers Questionnaire for (Risk Placement Services, Inc.)

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Plus Company Agents DataBreach and Brokers Questionnaire for (Risk Placement Services, Inc.)

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QBE and the links logo are registered service marks of QBE Insurance Group Limited
QBPC 30 03 09 15 Page 1 of 1
Instructions
This Questionnaire is for a premium estimate only.
Applicant information
1. (a) Full name of applicant
(b) Principal business premise street address
County
City
State
Zip
(c) Website(s)
2. Describe in detail the applicant’s business operations
3. Applicant's gross annual revenues
Total
E-Commerce
$
$
$
$
4. Does the applicant 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 compliant?
Yes
No
(i) If no, anticipated date of compliance?
6. Indicate the number of sensitive data records the applicant stores currently
7. Does the applicant 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
Signatures
Signing this Questionnaire does not bind the Company to provide or the applicant to purchase the insurance.
Applicant's name
Title
Applicant’s signature
Date
DataBreach
SM
Plus Company Agents
and Brokers Questionnaire for Breach
Mitigation Coverage
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signature
click to edit
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Plus Company Agents DataBreach and Brokers Questionnaire for (Risk Placement Services, Inc.)

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Completed 30 July 2020

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