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Cyber Liability Insurance Application
Cyber Liability Insurance Application
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Step
1
of 5
BASIC COMPANY DETAILS
Please complete the following details for the entire company or group (including all subsidiaries) that is applying for the insurance policy:
Company Name
*
Primary Industry Sector
*
Primary Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Description of Business Activities
*
Website / URL
*
Date Established
*
Last Complete Financial Year Revenue
*
Revenue From International Sales (%)
*
Next
PRIMARY CONTACT DETAILS
Please provide details for the primary contact for this insurance policy:
Contact Name
*
First
Last
Position
*
Email Address
*
Telephone Number
*
Next
COVERAGE REQUIRED
Please indicate which limit options you would like to receive a quotation for (if coverage is not required for a particular area please leave blank):
Cyber Incident Response
SELECT
$250k
$500k
$1m
$2m
$5m
Other
(other amount)
Cyber & Privacy Liability
SELECT
$250k
$500k
$1m
$2m
$5m
Other
(other amount)
System Damage & Business Interruption
SELECT
$250k
$500k
$1m
$2m
$5m
Other
(other amount)
Cyber Crime
SELECT
$250k
$500k
$1m
$2m
$5m
Other
(other amount)
Next
PREVIOUS CYBER INCIDENTS
Please tick all the boxes below that relate to any cyber incident that you have experienced in the last two years (there is no need to highlight events that were successfully blocked by security measures):
(Select All That Apply)
Cyber Crime
Cyber Extortion
Data Loss
Denial of Service Attack (DoS)
IP Infringement
Malware Infection
Privacy Breach
Ransomware
Other
(if selecting "other", please specify)
If you ticked any of the boxes above, did the incident(s) have a direct financial impact upon your business of more than $10,000?
Yes
No
If yes, please provide more information below, including details of the financial impact and measures taken to prevent the incident from occurring again:
Next
IMPORTANT NOTICE
By signing this form you agree that the information provided is both accurate and complete, and that you have made all reasonable attempts to ensure that this is the case by asking the appropriate people within your business. Thompson Professional Insurance Agency, LLC will use this information solely for the purposes of providing insurance services and may share your data with third parties in order to do this.
Contact Name
*
First
Last
Position
Signature
Clear Signature
(Please use your mouse or touch screen to input your signature)
Date
Comment
Submit