Cyber Liability Insurance Incident Disclosure Form
Insured Company Details
Company Name
Policy Number
Contact Person
Contact Email
Contact Phone
Incident Details
Date of Incident
Date Discovered
Type of Incident
Data Breach
Malware/Ransomware
Phishing
DDoS Attack
Unauthorized Access
Other
Incident Description
Systems/Data Affected
Actions Taken
Authorities & Notifications
Authorities Notified
Notifications Made to Affected Parties
Supporting Documentation
List of Attached Documents
Declaration
Name
Title/Position
Date