Cyber Insurance Policy Form

CYBER INSURANCE POLICY FORM

1. Insured Information

Individual Corporation LLC Partnership Other

2. Policy Details

Policy Number:

First-Party Cyber Third-Party (Liability) Media/Management Liability

Policy Period From: to

3. Coverages (select applicable)

Data Breach Response — forensic investigation, notification, credit monitoring, legal and PR expenses

Business Interruption and Extra Expense — lost income and necessary extra expense resulting from a covered cyber event

Cyber Extortion — negotiation, payment, and related costs subject to insurer approval

Network Security & Privacy Liability — claims alleging failure to prevent unauthorized access, transmission of malware, privacy breaches, or unauthorized disclosure of confidential information

Media Liability — defamation, infringement arising from content hosted or distributed by the insured

Regulatory Defense & Penalties — defense costs and civil monetary penalties where insurable by law (subject to policy terms)

4. Exclusions and Limitations

The Insurer shall not be liable for loss, cost or expense directly or indirectly arising out of or contributed to by any of the following, except to the extent expressly included in an endorsement attached hereto: (a) deliberate, dishonest or criminal acts of the Insured not reported promptly to the Insurer and not disclosed in the application; (b) bodily injury, bodily illness, emotional distress, or property damage unless otherwise specifically endorsed; (c) failure to comply with materially applicable written industry-standard security practices after notice from the Insurer; (d) war, invasion, insurrection or terrorism unless specific terrorism coverage is set forth; (e) contractual liability assumed in a contract or agreement except to the extent the Insured would have been liable in the absence of the contract; (f) fines or penalties arising from criminal acts or fraudulent conduct of the Insured; and (g) prior known incidents as described in Section 6.

By checking this box, the Insured acknowledges review of the exclusions above and understands that coverage is subject to the full terms, conditions, limitations and exclusions of the policy.

5. Prior Acts, Claims and Loss History

Have you experienced any cybersecurity incident, claim or notice that could lead to a claim in the past 5 years? Yes No

6. Beneficiary Designation (for recoveries / subrogation proceeds)

Designate payee(s) for proceeds or recoveries in the event of settlement or subrogation. If none, state "Insured".

7. Claims Reporting & Documentation

Date of Loss / Discovery:

Attach or indicate available documentation (check all that apply):

Forensic report

System logs / audit trails

Notification letters to affected parties

Relevant contracts or service agreements

Police or regulatory reports

8. Declarations, Representations and Conditions

The Insured declares that the information contained in this form and any attachments is true, complete and correct to the best of the Insured's knowledge. The Insured warrants that no material facts have been withheld and that any matter which might influence acceptance of coverage or the terms thereof has been disclosed. The Insured agrees that this form and any other information furnished by or on behalf of the Insured shall form the basis of the policy and shall be considered material representations.

The Insured agrees to cooperate with the Insurer in the investigation, settlement or defense of any claim, including providing access to records, personnel and systems as reasonably required. The Insured authorizes the Insurer to obtain and share underwriting and claims-related information with reinsurers and other insurers for underwriting and claims administration purposes.

The Insured acknowledges that timely reporting of incidents is a condition precedent to coverage. Failure to report a covered incident promptly may prejudice coverage or result in denial of a claim to the extent permitted by law. The Insurer reserves all rights, defenses, terms and conditions under the policy, including but not limited to subrogation rights and allocation of costs between covered and non-covered matters.

Fraud Warning: Any intentional misrepresentation, omission of material facts, or fraudulent statement made with respect to this application or in support of a claim may result in denial of coverage and may be grounds for rescission or other remedies available to the Insurer under applicable law.

9. Certification and Signature

By signing below, the undersigned certifies that the statements and particulars contained in this Cyber Insurance Policy Form and any attachments are complete and accurate. The undersigned authorizes the Insurer to rely upon these statements in determining coverage and premium. The undersigned acknowledges that acceptance of coverage is subject to the Insurer's review and issuance of a policy or endorsement and that no coverage is in force until a policy is issued or otherwise confirmed in writing by the Insurer.

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