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Cyber Risk Renewal Questionnaire
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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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
What is the applicant’s website address? (Enter http:// or https:// first)
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 first name of the contact person for the applicant?
What is the last 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 their phone number?
What is the applicant's expiring cyber policy number?
What is the applicant's expiring cyber policy number?
What year was the applicant’s business established?
What year was the applicant’s business established?
What is the applicant's NAICS code?
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 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 were the annual revenues of the applicant’s business as of the most recent fiscal year-end?
What type of entity is the applicant?
What type of entity is the applicant?
Select
Private
Nonprofit
Financial Institution
Publicly Traded
Franchisor or Franchisee
Homeowner or Condo Association
Other
Requested Insurance Terms
Does the Applicant desire any changes to the expiring policy limits or retentions?
Does the Applicant desire any changes to the expiring policy limits or retentions?
Yes
No
What aggregate limit is the Applicant requesting?
What aggregate limit is the Applicant requesting?
What retention 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?
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.
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?
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?
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?
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?
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?
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?
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?
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?
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?
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)?
Is the Applicant currently compliant with Payment Card Industry Data Security Standards (PCI-DSS)?
Yes
No
Not Applicable
Is the Applicant HIPAA compliant?
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?
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?
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?
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?
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?
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 full name.
Enter the authorized signer's title.
Enter the authorized signer's title.
Enter authorized signer's signature.
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 name of the agency.
Please enter the producer's name.
Please enter the producer's name.
Please enter the producer's license number.
Please enter the producer's license number.
Please enter the agency's phone number.
Please enter the agency's phone number.
Please enter the agency's email address.
Please enter the agency's email address.
Please enter the agency's address.
Please enter the agency's address.
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Documents and Comments
Please use this field to upload any relevant insurance documents.
Please use this field to upload any relevant insurance documents.
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 10.
Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
How did you hear about us?
How did you hear about us?
Current customer
Referred by...
Google search
Agency's website
Email newsletter
Facebook
Instagram
Twitter
Other
Please share who referred you to us.
Please share who referred you to us.
Please share what you typed into Google.
Please share what you typed into Google.
Please share how you heard about us.
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. *
*
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 *
AJG (Ericson) Service
860-868-7361
www.ericsoninsurance.com
GGB.WashingtonDepot.Service@ajg.com
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