Insurance Cyber Application

INSURANCE CYBER APPLICATION

Applicant / Insured Information

Policy Details Requested

Policy Type (select one or more):

Coverage Options

Select coverages requested (check applicable):

Security Controls and Risk Management

Please indicate current security measures implemented (check all that apply):

Prior Claims and Loss History

Have you experienced any cyber incidents, privacy claims, or security breaches in the past 5 years?

Exclusions and Limitations

The proposed policy will contain standard exclusions including, but not limited to, the following. Indicate whether any additional exclusion language is requested:

• Intentional illegal acts or fraudulent conduct by the insured;
• War, nuclear hazard, and acts of state;
• Bodily injury and property damage arising from physical causes (except as expressly provided);
• Failure to maintain required security controls where such failure materially contributed to loss;
• Prior known incidents or circumstances disclosed in this application.

Beneficiary / Payee Information

Designate the payee(s) for first-party payments, if different from the named insured.

Declarations, Certifications and Authorizations

By signing below, the Applicant certifies, represents, and agrees as follows:

1. The information provided in this application is true, complete and accurate to the best of Applicant's knowledge. Applicant understands that material misstatements or omissions may permit the insurer to void coverage or deny claims.
2. Applicant authorizes the insurer and its representatives to make inquiries and obtain records, including security assessments, claims history, and other information necessary to evaluate the application and administer any resulting policy.
3. Applicant warrants that all security controls described in this application are currently in operation and will be maintained through the policy period unless the insurer is notified in writing prior to any change.
4. Applicant acknowledges that coverage, limits, and terms are subject to underwriting review and that this application does not bind the insurer to provide coverage.
5. Applicant agrees to cooperate with the insurer in the event of a claim, including timely notification, preservation of evidence, and engagement of approved forensic providers when requested.

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