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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


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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
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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.
Location
Mailing Address Only
P.O. Box 868
Oakhurst, NJ 07755
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