Cyber Worksheet PDF Download Cyber Worksheet Agency InformationAgency Name* Agency Contact Name* First Last Agency Email Address* Basic InformationCompany Name* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website* Annual Revenue of Last Fiscal Year*Number of Employees*Security Contact Information:Company Contact Name* First Last Company Contact Email* Company Contact Phone*Industry* I confirm that the applicant does NOT operate in any of the following: Cannabis, Online Gambling, Adult Content* I confirm that the applicant does NOT operate in any of the following: Cannabis, Online Gambling, Adult Content Insurance and ClaimsDoes the applicant currently carry a standalone cyber policy?* Yes No Please enter current cyber policy expiration date* MM slash DD slash YYYY Claim activity*In the last 5 years, has the company suffered any cyber event, unscheduled network outage over 4 hours, loss or claim that would fall within the scope of the policy for which the applicant is applying? Yes No Loss Amount*Date of Notice* MM slash DD slash YYYY Describe the cyber event* What has the applicant done since the event to prevent future claims?* Legal Questions The applicant has not had any legal action and\or regulatory action brought or threatened against them in the last five years as a direct result of a cyber event. The applicant or any other person or organization proposed for this insurance is not 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? Within the last 3 years, the applicant has not been subject to any complaints concerning the content of its website, advertising materials, social media, or other publications. Security Controls1. Multi-factor authentication (MFA) - Does the applicant have multi-factor authentication enabled on email access, remote access & network administration?* Yes No I don't know 2. How many PII, PHI or PCI records does the applicant collect, process, store, transmit, or have access to?* No Records < 100K 100K - 250K 250K - 500K 500K - 1M > 1M I dont' know 3. How many biometric information records or data (i.e fingerprints, retinal scans, etc.) does the applicant collect, process, store, transmit, or have access to that can be used to uniquely identify a person?* No Records < 100K 100K - 250K 250K - 500K 500K - 1M > 1M I dont' know 4. Does the applicant keep online backups for all critical data that are disconnected from its network or store backups with a cloud service provider?* Yes No I don't know How frequently does it run?* Continuously Daily Weekly Monthly More than monthly I dont' know 5. Does the applicant implement encryption on laptop computers, desktop computers, and other portable media devices for all sensitive information?* Yes No I don't know 6. What is the estimated annual volume of payment card transactions (credit cards, debit cards, etc.)?* No payment card transactions < 100K 100K - 500K 500K - 1M > 1M I dont' know If relevant , is the applicant or their outsourced payment processor PCI-DSS compliant? Yes, applicant does not use outsourced payment processor Yes No I don't know 7. Does the applicant require a secondary means of communication to validate the authenticity of funds transfers (ACH, wire, etc.) requests by at least 2 employees before processing a request in excess of $25,000?* Yes No I don't know 8. Does the applicant enforce procedures to remove content (including third party content) that may infringe or violate any intellectual property or privacy right?* Yes No I don't know CommentsThis field is for validation purposes and should be left unchanged.