Cyber Liability Insurance Application Form

Applicant Information

Company Name Contact Name Email Phone Number Address Industry Number of Employees Annual Revenue

Coverage Information

Requested Coverage Amount Policy Effective Date

Cyber Security Details

Do you have dedicated IT staff? Yes No Do you have written cyber security policies? Yes No Is multi-factor authentication in use? Yes No Is sensitive data encrypted? Yes No

Claims History

Have you had previous cyber incidents or claims? Yes No If yes, please provide details

Declaration

Additional Information or Comments