Cyber Insurance Quick Quote

Name of Applicant*
Applicant's Annual Revenue (as of most recently completed Fiscal Year End)*
Email Address*
Applicant's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Applicant's Websites
Applicant's Primary Industry
Is the Applicant engaged in any of the following business activities? (select all that apply)
- Managed IT service provider (MSP or MSSP)
- Debt collection agency
- Payment Processing (e.g., as a payment processor, merchant acquirer, or Point of Sale system vendor)
- Gambling
- Cryptocurrency or Blockchain
- Cannabis
- Adult Content
- None of the above
Security Controls
Does the Applicant encrypt all sensitive information at rest?*
Does the Applicant keep offline backups that are disconnected from its network or store backups with a cloud service provider?*
Does the Applicant store or process personal, health, or credit card information of more than 500,000 individuals?*
If yes, please approximate the number of individuals:
Does the Applicant have multi-factor authentication enabled on email access and remote network access?*
Does the Applicant have controls in place which require all fund and wire transfers over $25,000 to be authorized and verified by at least two employees prior to execution?*
Insurance
In the last three (3) years, has the Applicant experienced in excess of $10,000 any Cyber Event, Loss, or been the subject of any Claim made for a Wrongful Act that would fall within the scope of the Policy for which the Applicant is applying?*
If yes, please provide additional details.
Is the Applicant aware of any fact, circumstance, situation, event, or Wrongful Act which reasonably could give rise to a Cyber Event, Loss, or a Claim being made against them that would fall within the scope of the Policy for which the Applicant is applying?*
If yes, please provide additional details.
What are the desired limits?*
Today's Date*
MM slash DD slash YYYY
Authorized Representative Title*
Authorized Representative Name*
Authorized Representative Signature*

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