Insurance Cyber Liability Renewal Form

INSURANCE CYBER LIABILITY RENEWAL FORM

Insured / Applicant Information

Individual Corporation LLC Partnership Other

Policy Details (Renewal)

Policy Period: From to . Retroactive Date (if applicable):

Coverage Options & Limits

Select coverages to be included in the renewed policy and indicate proposed sublimits where different from the policy limit.

Privacy Liability (third-party privacy claims) — Sublimit:

Network Security Liability (failure of security controls) — Sublimit:

Incident Response Costs (forensic, legal, notification) — Sublimit:

Regulatory Defense & Penalties (where insurable) — Sublimit:

Business Interruption & Extra Expense — Sublimit:

Data Restoration & Services — Sublimit:

Exclusions, Endorsements & Changes

The renewed coverage will remain subject to all policy terms, conditions and exclusions. Standard exclusions include, but are not limited to, willful fraudulent acts, bodily injury/property damage liability, and coverage for criminal acts knowingly performed by the Insured. Any requested endorsements will be considered and may alter premium or terms.

Acknowledged

Material Changes Since Prior Policy

Has there been any material change to operations, exposures, data volume, or vendor relationships since the prior policy period?

No material changes Yes — describe below

Claims / Loss History (Last 3 Years)

Risk Management & Cybersecurity Controls

Indicate the current state of cybersecurity controls in operation.

Perimeter firewall in place Endpoint detection & response

Multi-factor authentication for remote access Encryption of sensitive data at rest

Written breach response plan maintained

Beneficiary / Payee Designation

Designate an entity or individual to receive any covered first-party payments in the event of loss where applicable under the policy.

Premium, Billing & Payment

Invoice Annual Installments Direct Debit (ACH)

Declarations, Representations & Authorizations

By signing below the Insured declares that the statements and information contained herein are complete, true and correct to the best of the Insured's knowledge. The Insured understands and agrees that any material misstatement, omission or concealment of fact may result in voidance of coverage or denial of a claim for relief under the renewed policy.

The Insured authorizes the insurer and its representatives to obtain and exchange underwriting, claims, loss history and cyber security audit information with prior insurers, service providers, and other third parties as necessary to underwrite the renewal and to administer any claims. Renewal acceptance and issuance of any endorsement remain subject to insurer underwriting approval and receipt of required premium.

The Insured agrees to provide prompt written notice to the insurer of any actual or suspected security incident or breach as soon as practicable and, in any event, within 72 hours of discovery where feasible. Failure to provide timely notice that materially prejudices the insurer's rights may affect coverage.

Insured consents to the exchange of underwriting and claims information as described above

Certification

I certify that I am authorized to bind the named Insured and that the information provided on this renewal form is accurate and complete. I understand that coverage under the renewed policy will be effective only upon issuance of the renewal endorsement and payment of any required premium. I further certify that I will notify the insurer of any material change in the facts provided herein between the date of this application and the effective date of renewal.

Sign Now