Cyber Worksheet

Agency Information

Agency Name*

Agency Contact Name*

First Last

Agency Email Address*

Basic Information

Company Name*

Address*

Street Address Address Line 2 City 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 Claims

Does the applicant currently carry a standalone cyber policy?*

Yes
No

Please enter current cyber policy expiration date*

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*

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 Controls

1. 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?*

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?*

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?*

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.)?*

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

Phone

This field is for validation purposes and should be left unchanged.