Insurance Cyber Liability Application

INSURANCE CYBER LIABILITY APPLICATION

Applicant / Insured Information

Business Operations and Exposures

Primary business activity:

Policy Details Requested

Requested Policy Effective Date:

Coverage Options (select all requested)

First-Party Data Breach Response (forensic, notification, credit monitoring)

Privacy Liability (third-party claims for privacy breach)

Media Liability (defamation, IP infringement arising from online content)

Ransomware / Cyber Extortion Coverage

Business Interruption and Extra Expense due to covered cyber incident

Regulatory Defense and Penalties (where insurable by law)

Security Controls & Risk Management

Please indicate which of the following controls are implemented and maintained by the applicant:

Network firewall(s) in place

Multi-factor authentication for remote access and privileged accounts

Encryption of sensitive data at rest and in transit

Formal incident response plan documented and tested

Regular off-site backups and disaster recovery procedures

Periodic penetration testing / vulnerability assessments

If penetration testing or assessments performed, most recent test date:

Claims, Losses and Prior Acts

Has the applicant suffered any actual or alleged security breach, privacy incident, ransomware event, or claim in the past five (5) years?

Yes    No

Exclusions / Known Limitations

The proposed coverage will not apply to losses caused by or resulting from: war, insurrection, nuclear hazard, intentional fraudulent acts committed by insured persons, bodily injury or physical property damage not arising from a covered cyber event, and any claim or circumstance known to the applicant prior to the effective date. Additional exclusions or conditions may apply in the policy form and endorsements; the insurer reserves the right to amend coverage terms based on underwriting findings.

Beneficiary / Loss Payee Information

Complete only if a third-party payee or beneficiary is required for payment of first-party proceeds (e.g., lender or other loss payee):

Attachments / Documentation Checklist

Please indicate attached documentation to accompany this application:

Network architecture diagram

Information security policy documentation

Latest penetration test / vulnerability assessment report

Recent financial statements

Representations, Warranty and Certification

The undersigned authorized representative of the applicant certifies, to the best of their knowledge and belief, that the information contained in this application and any attachments is true, complete and will form the basis of any contract of insurance issued. The applicant acknowledges that any material misrepresentation, omission, or inaccuracy may be a basis for denial of coverage or rescission of the policy. The applicant further authorizes the insurer and its representatives to make inquiries and obtain records necessary for underwriting, whether obtained directly or through third-party reports. This application does not bind coverage or alter any underwriting requirements; coverage will be effective only upon issuance of a policy and receipt of premium as required by the insurer.

By checking this box, I certify that the statements in this application are accurate and complete and that I am authorized to provide this certification on behalf of the applicant.

Additional Information

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