Cybersecurity Breach Insurance Claim Notification Form

Policyholder Information

Company Name Contact Person Email Address Phone Number Policy Number

Breach Incident Details

Date of Breach Date Discovered Time of Breach (if known) Type of Breach Hacking/IT Incident Malware/Ransomware Insider Threat Phishing Attack Lost/Stolen Device Other Description of the Incident

Impact Assessment

Systems/Data Affected Number of Individuals Affected Actions Taken

Law Enforcement & Regulator Notification

Notified Law Enforcement? Yes No Notified Data Protection/Regulatory Authority? Yes No