Cyber Liability Questionnaire

Section 1: Applicant Information


Section 2: Nature of Operations

Does the Applicant currently or will the Applicant potentially operate as any of the following? *
• Accreditation Services Provider
• Adult Content Provider
• Credit Bureau
• Cryptocurrency Exchange
• Data Aggregator/Broker/Warehouse
• Direct Marketer
• Gambling Services Provider
• Manufacturer of Life Safety Products/Software
• Media Production Company
• Payment Processor
• Peer To Peer File Sharing
• Social Media
• Surveillance
• Third Party Claims Adminstrator
Does the Applicant derive more than 50% of its revenue from technology products and services (e.g. software, electronics, telecom)? *

Section 3: Current Loss Information

Within the past three years, has the Applicant had any actual or potential Incidents or Claims to which the Policy would apply; or is the Applicant aware of any fact, circumstance, or situation that could reasonably be expected to give rise to an Incident or Claim to which the Policy would apply? *

Section 4: Cyber and Media Controls

Which of the following IT security controls does the Applicant have in place? *
1) Antivirus and Firewalls (Windows 7 or higher qualifies)
2) Encryption of Sensitive Data
3) Encryption of Mobile Computing Devices
4) Critical Software Patching Procedures
5) Critical Data Backup and Recovery Procedures
6) Formal Cyber Incident Response Plan
Does the Applicant accept payment card (Credit/debit card) transactions? *
If Yes, is the Applicant PCI compliant? (via assessment or self-attestation)?
Does the Applicant deal with protected health information as defined by HIPAA? *
If Yes, is Applicant compliant with HIPAA and the HITECH Act?
Does the Applicant have operations or customers in California, or any responsibilities under the California Confidentiality of Medical Information Act? *
Has the Applicant obtained legal review of its use of trademarks, including domain names? *

Section 5: Current Coverage

Does the Applicant currently purchase Cyber or Privacy Liability insurance? *

Section 6: Contact information for person completing this application

Please note

This information will be shared with an insurance carrier to determine a pricing indication. In order to bind coverage, a formal application, warranty statement and specific loss information will be required.