Data Breach / Cyber Liability Form

GENERAL INFORMATION

Company Name: *

Address *

Company Point of Contact *

Telephone: *

E-mail *

Website URL’s:

Date Business Established

Business Description

Total Estimated Gross Annual Revenue:

Management Of Privacy and Data Exposures

Total Number of employees

	Full Time
	Part Time (including temporary)
	Independent Contractors
	Leased
	Seasonal

0/100 points

Do you have a written corporate-wide privacy policy regarding the protection and safeguarding of client and company info?

Yes

No

Do you accept credit cards for goods sold or services rendered?

Yes

No

If yes, are you in compliant with applicable data security standards issued by financial institutions that you transact with (e.g. PCI standards)?

Yes

No

Are you aware of any release, loss or disclosure of personally identifiable information in its care, custody or control, or anyone holding such information on behalf of you in the most recent three year time period from the date of this Application?

Yes

No

If yes, please describe:

Computer System Controls

Do you publish and distribute written computer and information systems policies and procedures to its employees?

Yes

No

Does the applicant have:

a disaster recovery plan?

Yes

No

a business continuity plan?

Yes

No

an incident response plan for network intrusions and virus incidents?

Yes

No

Do you use commercially available firewall protection?

Yes

No

Do you use commercially available antivirus protection?

Yes

No

Do you terminate all computer access and user accounts as part of the regular exit process when an employee leaves the company?

Yes

No

Please provide the Name / Email and Phone Number of the employee of the that is designated to manage a response, including consumer notification, in response to a data breach event

Do you have, and enforce, policies concerning when internal and external communication should be encrypted?

Yes

No

Do you encrypt data stored on laptop computers, back-up tapes and all other portable media?

Yes

No

Do you encrypt data “at rest” within computer databases?

Yes

No

Do you enforce a software update process including installation of software “patches”?

Yes

No

Have you suffered any known intrusions (i.e., unauthorized access or security breach) or denial of service attacks relating to its computer systems in the most recent three (3) year time period from the date of this Application If yes, describe any such intrusions or attacks:

Yes

No

If yes please provide details

Website Content Controls

Do you have a process to review all content prior to posting on the Insured’s Internet Site?

Yes

No

If you do not have a process to review all content prior to posting, please describe procedures to avoid the posting of improper or infringing content:

Within the last three (3) years, have you ever received a complaint or cease and desist demand alleging trademark, copyright, invasion of privacy, or defamation with regard to any content published, displayed or distributed by or on behalf of you?

Yes

No

If yes, please provide details regarding any such demands:

3rd Party Applications

Do you or a third party service provider on behalf of you, collect non-employee (client) personal identifiable information (name, address, credit cards, social security #, driving license, medical records)

Yes

No

If “Yes”, # of records (clients, files)

If “Yes”, do over 10% of these records contain medical or financial account information (other than credit card information)?

Yes

No

Do you or a third party service provider to store / collect / keep track of client or customer information (name, address, credit cards, social security #, driving license, medical records)?

Yes

No

If yes please provide the the 3rd Party Application and Details

Prior Insurnace

Do you currently have insurance in place covering media, privacy or network security exposures?

Yes

No

If yes, please provide the following:

Insurance Company:

Limits (If Known)

Deductible (If Known)

Policy Renewal Date

Current Premium

Retroactive Date (If Known)

Prior Claims and Circumstance

Have you ever received any claims or complaints with respect to allegations of invasion of or injury to privacy, identity theft, theft of information, breach of information security, software copyright infringement or content infringement or been required to provide notification to individuals due to an actual or suspected disclosure of personal information?

Yes

No

If yes, Provide details of each such claim, allegation or incident, including costs, losses or damages incurred or paid, and any amounts paid as a loss under any insurance policy:

Have you been subject to any government action, investigation or subpoena regarding any alleged violation of any law or regulation?

Yes

No

If yes, please provide details of any such action, investigation or subpoena:

Have you ever experienced an extortion attempt or demand with respect to its computer systems?

Yes

No

If yes, please provide details:

Have you notified consumers of a data breach incident in accordance with a data breach notification law in the past three (3) years?

Yes

No

If yes, please provide details:

Have you, or any director, officer, employee or other proposed insured have knowledge or information of any fact, circumstance, situation, event or transaction which may give rise to a claim or privacy breach notification under the proposed insurance?

Yes

No

If yes, please provide details: