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Note: this is not a valid policy and
does not ensure coverage.
Authorized Signatory Date
Company Information
Name of Insured Email:
Address
City State Zip
Industry Gross Revenue
Risk
Do you back up your data at least once a week and store it in an offsite location or your outsourcer does?
YES NO
Do you have antivirus and firewalls in place and are these regularly updated (at least quarterly)?
YES NO
HEALTHCARE ENTITIES ONLY:
Do you have a written policy that requires that personally identifiable
information stored on mobile devices (e.g. laptop computers/smartphones) and portable media (e.g. flash
drives/back-up tapes) be protected by encryption?
YES NO
Coverage
Limit of Liability
$1,000,000 $2,000,000 $3,000,000 $5,000,000
Have you previously purchased a Cyber Policy? YES NO
No Claims Declaration
Are you aware of or have any grounds for suspecting any circumstances which might give rise to a claim?
YES NO
Within the last 5 years have you suffered any systems intrusion, tampering, virus or malicious code attack,
loss of data, loss of portable media, hacking incident, extortion attempts, data theft or similar, resulting in a
claim that would have been covered by this insurance?
YES NO
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