Cyber Risk Renewal Questionnaire

Applicant Information

What is the name of the applicant? **

What is the name of the applicant? *

What is the applicant’s address? **

What is the applicant’s address? *

Street Address Address Line 2 City State ZIP Code

What is the applicant’s website address? (Enter http:// or https:// first)

What is the applicant’s email address? **

What is the applicant’s email address? *

What is the first name of the contact person for the applicant?

What is the last name of the contact person for the applicant?

What is their phone number?

What is the applicant's expiring cyber policy number?

What year was the applicant’s business established?

What is the applicant's NAICS code?

What were the total assets of the applicant’s business as of the most recent fiscal year-end?

What were the annual revenues of the applicant’s business as of the most recent fiscal year-end?

What type of entity is the applicant?

Requested Insurance Terms

Does the Applicant desire any changes to the expiring policy limits or retentions?

Yes
No

What aggregate limit is the Applicant requesting?

What retention is the Applicant requesting?

Solely with respect to increased limits, is the Applicant, any Subsidiary, or any person proposed for this insurance aware of any circumstance that could give rise to a claim against them under this Cyber risk coverage?

Yes
No

Please provide details of the circumstances that could give rise to a claim under this Cyber risk policy.

Underwriting Information

Does the Applicant have Up-to-date, active firewall technology?

Yes
No
Not Applicable

Does the Applicant have Up-to-date, active anti-virus software on all computers, networks, and mobile devices?

Yes
No
Not Applicable

Does the Applicant have a process in place to regularly download and install patches?

Yes
No
Not Applicable

Does the Applicant have backup and recovery procedures in place for all important business and customer data?

Yes
No
Not Applicable

Does the Applicant have an incident response plan to respond to a network intrusion?

Yes
No
Not Applicable

Does the Applicant have a disaster recovery plan, business continuity plan, or equivalent to respond to a computer system disruption?

Yes
No
Not Applicable

Does the Applicant have controls to ensure the content of media communications and websites are lawful?

Yes
No
Not Applicable

Does the Applicant have procedures in place which require service providers with access to the Applicant’s systems or the Applicant’s confidential information to demonstrate adequate network security controls?

Yes
No
Not Applicable

Does the Applicant have multi-factor authentication for remote access to email and other systems and programs that contain private or sensitive data in bulk?

Yes
No
Not Applicable

Is the Applicant currently compliant with Payment Card Industry Data Security Standards (PCI-DSS)?

Yes
No
Not Applicable

Is the Applicant HIPAA compliant?

Yes
No
Not Applicable

Does the Applicant encrypt private or sensitive data while at rest in the Applicants’s database or on the Applicant’s network?

Yes
No
Not Applicable

Does the Applicant encrypt private or sensitive data while in transit in electronic form?

Yes
No
Not Applicable

Does the Applicant encrypt private or sensitive data while on mobile devices?

Yes
No
Not Applicable

Does the Applicant encrypt private or sensitive data while on employee owned devices?

Yes
No
Not Applicable

Does the Applicant encrypt private or sensitive data while in the care, custody, and control of a third party service provider?

Yes
No
Not Applicable

Insured Signature

Enter the authorized signer's full name.

Enter the authorized signer's title.

Enter authorized signer's signature.

Agency Information

This section is for the agent to complete.

Please enter the name of the agency.

Please enter the producer's name.

Please enter the producer's license number.

Please enter the agency's phone number.

Please enter the agency's email address.

Please enter the agency's address.

Street Address Address Line 2 City State ZIP Code

Documents and Comments

Please use this field to upload any relevant insurance documents.

Drop files here or

Max. file size: 128 MB, Max. files: 10.

Please enter any additional remarks in the space below.

How did you hear about us?

Please share who referred you to us.

Please share what you typed into Google.

Please share how you heard about us.

Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *

I agree *

Cyber Risk Renewal Questionnaire

Applicant Information

Requested Insurance Terms

Underwriting Information

Insured Signature

Agency Information

Documents and Comments

Margaret Ann Pyburn

RiskRevu^TM Newsletter

Contact

Cyber Risk Renewal Questionnaire

Applicant Information

Requested Insurance Terms

Underwriting Information

Insured Signature

Agency Information

Documents and Comments

Margaret Ann Pyburn

Share This

RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter