Cyber Liability Endorsement Application Form
Insured Information
Named Insured
Mailing Address
City
State
Zip Code
Phone
Email
Website
Coverage Requested
Requested Effective Date
Limit of Liability
Deductible
General Information
Describe business operations
Number of employees
Annual gross revenue
Does your company collect or store Personally Identifiable Information (PII) or Protected Health Information (PHI)?
Yes
No
If yes, describe types of information
Current Coverage
Current cyber liability insurer
Current policy effective dates
Current limit / deductible
Any prior claims or incidents in the past 5 years?
Yes
No
If yes, provide details
Applicant Declaration
Name of Authorized Person
Title
Date