Let’s get your data protected with cybersecurity insuranceNeed coverage now? Fill out some info below for a free quote! Name of Organization (Applicant) * Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Policy Start Date MM DD YYYY Founding Year of Business Legal Entity Type Sole Propietorship Partnership LLC S Corporation C Corporation Joint Venture Trust Association Municipality Other Estimated Total Gross Revenue $ Number of employees not including the business owner(s) at the primary business address: Full-time employees Part-time Employees Past Claim History Never Within last 12 months Within last 2 years Within last 3 years Within last 4 years Within 5 years or more Does the policyholder encrypt all emails, mobile and computing devices containing sensitive information (e.g., PII, PHI, PCI) sent to external parties? Yes No Does the policyholder have sensitive information stored on the cloud? Yes No Do policy holder employees verify vendor/supplier bank accounts before adding to accounts payable systems? Yes No Do policy holder employees authenticate funds transfer requests (e.g. by calling a customer to verify the request at a predetermined phone number)? Yes No Do policy holder employees prevent unauthorized employees from initiating wire transfers? Yes No Approximately when did you business begin? Please enter the date that the business was established. MM DD YYYY Do you currently have an insurance policy in effect for the coverage requested? Yes No Prefer not to answer Do you conduct annual training for employees with respects to privacy matters? Yes No Cyber Occurence limit / Aggregate limit $250,000 / $250,000 $500,000 / $500,000 $1,000,000 / $1,000,000 Cyber Deductible $1,000 $5,000 $10,000 $15,000 $20,000 $25,000 Media Liability Include Do not include Cyber Terrorism Coverage Include Do not include How did you hear about us? Referred by a friend Mailing Ad Social Media Google Ad Other Thank you!
