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Cyber Liability Insurance Estimate
Name
(required)
First
Middle
Last
Company Name (Applicant)
(required)
Type of Business
(required)
Lawyer
Accountant
Insurance Agent
Title Agent
Realtor
Consultant
Investment Advisor
Other
Description of Business/Services provided:
(required)
Address
(required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone Number
(required)
Email
(required)
Website
(required)
Estimated Annual Revenue (expected over the next 12 months)
(required)
# of Full-Time Employees
# of Part-Time Employees
Date Business Established
Has the applicant ever suffered a cyber incident resulting in a claim?
(required)
Yes
No
Please explain:
(required)
Is the applicant aware of any circumstances that could give rise to a claim under this type of insurance policy?
(required)
Yes
No
Please explain:
(required)
Does the applicant enable disk encryption on laptops, desktops, and other portable media devices?
(required)
Yes
No
Sometimes
Does the applicant accept credit cards or collect Personally Identifiable Information (PII) or Protected Health Information (PHI) from its customers? (This does not include employees of the applicant.)
(required)
Yes
No
Does the applicant have procedures to back up, archive, and restore sensitive data and critical business systems?
(required)
Yes
No
Does the applicant electronically transfer funds?
(required)
Yes
No
Does the applicant have appropriate safeguards when transferring funds (e.g. verifying vendor bank accounts, unauthorized employees prevented from initiating transfers, and calling the customer at a predetermined phone number to confirm the request)?
(required)
Yes
No
If you have not previously transferred funds, will the above safeguard be required if transfers occur in the future?
(required)
Yes
No
Do you enforce MFA for email services?
(required)
Yes
No
Do you enforce MFA for Virtual Private Network (VPN), Remote Desktop Protocol (RDP), RDWeb, RD Gateway, or other remote access services?
(required)
Yes
No
Do you enforce Multi-Factor Authentication (MFA) for Network/cloud administration or other privileged user accounts services?
(required)
Yes
No
Name
This field is for validation purposes and should be left unchanged.
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