Cyber Liability Online Application

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Personal Information

First Name

Required

Last Name

Required

Number of Owners

Required

Name(s) of Company Owner(s), with % ownership

Required

Description of Operations:

Required

Formal Name of Business

Required

Is your company a franchise?

Required

If yes, provide full legal name of franchisor:

Optional

Business Type

Required

Year Established

Required

Street

Required

City

Required

State

Required

ZIP / Postal Code

Required

Primary Phone Number

Required

E-Mail Address

Required

Website Address:

Required

RISK BACKGROUND

Has any entity proposed for insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?

Required

Do you perform services in the State of New York?

Required

If “Yes,” what percentage is performed in the five (5) boroughs and what percent in the rest of New York?

Optional

Please list all States in which you operate.

Required

Estimated Annual Gross Revenue

Required

Prior 12 months annual gross revenue

Required

Number of full-time employees

Required

Number of part-time employees

Required

Number of temporary/ seasonal employees

Required

Number of independent contractors

Required

DATA AND RECORDS INFORMATION

Estimated number of individual client records whose information (credit card, soc sec #, etc.) is stored transmitted or collected by your company or any third party service provider on behalf of your client.

Required

Estimated number of foreign individuals whose personal information is stored, transmitted, or collected.

Required

Type(s) of personally identifiable information collected, transmitted, or stored"

Required

Hold down the Ctrl Key to make multiple selections.

# of records collected or transmitted each year: Social security # or individual taxpayer identification #s

Required

Maximum number of records stored at any one time: Social security # or individual taxpayer identification #s

Required

# of records collected or transmitted each year: Financial account record (e.g. bank accounts)

Required

Maximum number of records stored at any one time: Financial account record (e.g. bank accounts)

Required

# of records collected or transmitted each year: Payment card data (e.g. credit or debit cards)

Required

Maximum number of records stored at any one time: Payment card data (e.g. credit or debit cards)

Required

# of records collected or transmitted each year: Driver’s license # passport # or other State or Federal ID#

Required

Maximum number of records stored at any one time: Driver’s license # passport # or other State or Federal ID #

Required

# of records collected or transmitted each year: Protected health information (e.g. medical records)

Required

Maximum number of records stored at any one time: Protected health information (e.g. medical records)

Required

# of records collected or transmitted each year: Username/email address, in combination with password or security question

Required

Maximum number of records stored at any one time: Username/email address, in combination with password or security question

Required

# of records collected or transmitted each year: Other – Please provide details

Optional

Additional Comments

Optional

Maximum number of records stored at any one time: Other – Please provide details

Optional

Additional Comments

Optional

CURRENT CYBER LIABILITY/DATA BREACH POLICY INFO

Do you currently have a cyber liability/data breach insurance policy?

Required

Current Insurance Provider

Required

Effective Date

Optional

Current Policy End Date

Required

Current Limits

Required

Current Deductible

Required

Current Premium

Required

CLAIM ACTIVITY

In the last five years, has the applicant had a data breach resulting in the misappropriation or public disclosure of personal Information?

Required

In the last five years, has the applicant had any claim, suit, inquiry, complaint, notice of charge, notice of hearing, regulatory action, governmental action or administrative action related to the coverage applied for?

Required

WEBSITE MEDIA LIABILITY

Does the applicant have a website or utilize a social media platform?

Required

If “Yes,” please answer the following regarding the content used online:

Does the applicant review material that is posted or utilized online?

Required

Does the applicant obtain written releases from all images used

Required

Does the website have a privacy policy?

Required

Information/Network Security Risk Management

Select all the controls your company utilizies:

Required

Hold down the Ctrl Key to make multiple selections.

Does the applicant proactively address system vulnerabilities, including regular updates to anti-virus/ malware protection and critical security patches?

Required

Has the applicant had a vulnerability assessment, penetration test, or other network security assessment performed in the last 12 months?

Required

Does the applicant have a data retention and destruction plan in place that includes both electronic and physical data?

Required

Information/Network Security Policy

Does the applicant have a written physical and network security policy in place?

Required

Do all employees receive training on the privacy policy at least annually?

Required

Does the applicant have a designated individual responsible for the management of, and compliance with the applicant’s security policies?

Required

If “Yes,” what is the name and title of this individual?

Optional

Breach Response/Disaster Recovery/Business Continuity Planning

Does the applicant have a written data breach response plan in place?

Required

Does the applicant back up all valuable/sensitive data, including personal information* of others, on a daily basis?

Required

If not daily, how often?

Required

Does the applicant have a disaster recovery and business continuity plan in place that is designed to avoid business interruption due to IT systems failure?

Required

If "yes" Is this plan regularly tested and updated?

Optional

If "yes", how many hours does it take the applicant to fully restore their systems?

Optional

Encryption

Does the applicant encrypt personal information in the following scenarios?

Required

Hold down the Ctrl Key to make multiple selections.

Physical Security

Does the applicant have physical security in place to restrict access to computer systems or paper records that contain sensitive information?

Required

Vendor Controls

Are business associate agreements in place for all third parties?

Required

Has applicant confirmed payment processor and any third party assisting with payment cards is compliant with Payment Card Industry Data Security Standards? (PCIDSS)

Required

Have you entered into a written contract or agreement with a service provider or utilize a third party that holds, transmits, or stores personal information* on your behalf?

Required

If "yes" provide the Service Provider Name, Services Provided, Type of Personal Information stored and # of records stored

Optional

Employee Controls

Does the applicant conduct background checks on all employees?

Required

Does the applicant restrict employee access to Personally Identifiable Information on a business “need-to-know” basis?

Required

Is remote access to the network permitted only if through Virtual Private Network (VPN) or equivalent system?

Required

Does applicant terminate all associated computer access and user accounts as part of the regular exit process when an employee leaves the company?

Required

Do you track and monitor all access to network resources?

Required

Additional Comments

Optional

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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P.O. Box 868
Oakhurst, NJ 07755