This non-binding premium indication form is for a "non-binding premium estimate" for the prospective insured. A contract of insurance cannot be confirmed and the resulting indication is subject to change.

Section I – General Information

Name of Company: *

Company Address: *

City: *

State: *

Zip: *

Website: *

Telephone: *

Nature of operations of Insured: *

Annual revenue: *

Number of employees: *

Section II – Risk Controls

Do you have a firewall? *

Yes

No

Do you have a virus protection program in place?? *

Yes

No

Do you have a person responsible of information safety? *

Yes

No

Do you outsource a critical part of your internal network/computer system or internet access/presence to others? *

Yes

No

If yes to the above question, please explain.

Do you have a written privacy or security policy? *

Yes

No

Do you control access to your computer systems? *

Yes

No

Does your hiring process include criminal background checks? *

Yes

No

Have you ever experienced a privacy breach or security breach? If yes, explain via a separate sheet. *

Yes

No

Do you have a program in place to test your security/privacy controls, including the services of your vendors? *

Yes

No

Do you allow employees to download Personally Identifiable Information of customers or confidential information in your care belonging to third parties onto laptops or other storage media? *

Yes

No

If yes to the above question, is the information encrypted?

Yes

No

Types of Personally Identifiable Information held (check all that apply).

Do you hold Personal Identifiable Information other than those listed above? Please explain.

Contact Person: *

Date: *

Email Address: *

Any offer of insurance coverage resulting from the submission of this non-binding premium estimate sheet will be an estimate of premium costs, forms, terms, and conditions. To secure a bindable quotation, it will be necessary to complete a Cyber Security Liability Insurance application and submit all required attechments.

Social Security Numbers	Bank Account Details
Credit Card Numbers	Drivers Licenses
Personal Health Information