Cyber Insurance Application

Step 1 of 4

Contact and company

Contact name

Phone number

Contact email

Company full legal name

Start year of business

Annual revenue

Company websiteURL or domain - enter all that apply.

Company address

Step 2 of 4

Policy details

Anticipated cyber policy start date

Requested policy limit

Estimated number of personal information records (PII or PHI) and payment card transaction records

Business industry

Total number of employees including owners and contractors with access to your systems

Step 3 of 4

Security controls

Does your organization encrypt emails, mobile devices and computing devices containing sensitive information sent to external parties?

Does the applicant use an email security filtering tool?

Do you implement Multi-Factor Authentication for remote access?

Do you have MFA in place for email access?

Do you have MFA in place for critical systems, applications and servers?

Does your organization use an EDR tool with centralized monitoring?

Does your organization store sensitive information in the cloud?

How often does your organization back up business-critical data?

How quickly are critical updates applied when a patch is released?

Is annual cybersecurity awareness training mandatory for all employees with system access?

Before executing an electronic payment, do you verify funds transfer or payment change requests with the requestor via a separate means of communication?

Step 4 of 4

Review and certify

Describe the organization's products and services, including any contractual insurance requirements such as Additional Insured

Any prior cyber claims?

Any anticipated cyber claims or known circumstances that may give rise to a claim?

Any regulatory investigation or citation?

Currently involved in any lawsuits?

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that this application is used for insurance underwriting purposes and does not bind or guarantee coverage.

Client or applicant name

Position or title

Signature - type your full name

Signature date

Electronic or typed signatures are acceptable if permitted by the receiving insurer.

Cyber insurance application

Contact and company

Policy details

Security controls

Review and certify