Insurance Claim Cyber Applications

INSURANCE CLAIM - CYBER APPLICATIONS

1. Insured / Claimant Information

2. Policy Details

3. Incident / Loss Details

Date of Incident:    Time (if known):    Date Discovered:

4. Method of Compromise (select all that apply)

Phishing / Social Engineering Malware / Ransomware Vulnerability / Exploit Insider Action / Privileged Misuse Compromise via Third-Party Supplier Unknown / Under Investigation Other:

5. Impact, Damages and Estimates

Estimated Financial Loss (direct costs): $    Estimated Business Interruption Loss: $

Personal Identifiable Information (PII) Payment Card Information Health / Medical Records Confidential Business Information / IP Other:

6. Forensic, Notification & Extortion

Was a forensic firm engaged? Yes No

Notification Costs Incurred: $    Extortion / Ransom Demands: Yes No

7. Coverage Categories (for claim handling)

Indicate coverages for which this claim is submitted (select applicable):
Forensic Investigation Costs Notification & Credit Monitoring Costs Business Interruption Loss Cyber Extortion / Ransom Third-Party Liability (defense and damages) Crisis Management / Public Relations Regulatory Defense & Fines (where insurable)

8. Exclusions & Acknowledgements

The policy may exclude coverage for certain losses, including but not limited to: acts of war or terrorism, intentional wrongful acts by the insured, loss arising from known or pending claims prior to inception, or failure to implement required security controls. Submission of this claim does not constitute acceptance of coverage. The insurer reserves all rights to investigate, adjust, and determine coverage under the policy.

I acknowledge that I have read the foregoing paragraph and that the information provided in this claim is true, complete and accurate to the best of my knowledge. I understand that fraudulent statements or omissions may result in denial of coverage and may subject me to penalties under applicable law.

9. Payment / Beneficiary (Payee) Information

10. Documentation Checklist

Please indicate and provide copies of available documents. Additional documentation may be requested as part of investigation.

11. Declaration, Authorization & Certification

By signing below, I certify that the statements contained in this claim form and in any accompanying documents are true, complete and accurately describe the incident and losses claimed. I authorize the insurer and its representatives to obtain records and information reasonably related to this claim, including but not limited to electronic logs, forensic reports, financial records, and third-party communications. I agree to cooperate fully with the insurer in its investigation and to take reasonable steps to mitigate further loss. I acknowledge that any payment of this claim is conditional upon proof of loss and the insurer's final determination of coverage and entitlement.

Subrogation and Recovery: I agree to assign to the insurer any rights of recovery against third parties for amounts paid under this claim and to execute instruments necessary to secure such rights. I will not admit liability, make settlement offers, or incur defence costs on behalf of the insurer without prior written consent.

Fraud Warning: Any person who knowingly and with intent to defraud presents a false or fraudulent claim for payment of a loss or benefit may be subject to criminal and civil penalties.

12. Additional Remarks

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