Insurance Cyber Security Application

INSURANCE CYBER SECURITY APPLICATION

Complete this application in full. The statements and particulars contained herein are material to the underwriting of requested insurance coverage. Any person who knowingly submits false information may be subject to penalties including the rescission of coverage. Answers must reflect the Insured as of the signature date below.

1. Applicant / Insured Information

2. Policy Details Requested

Policy Type: First‑Party Coverage Third‑Party Liability Combined Package

3. Business & Information Technology Profile

Personal Identifiable Information Financial / Payment Card Data Health / Medical Records Intellectual Property / Trade Secrets Other (specify below)

4. Security Controls and Risk Management

Does the applicant employ the following controls? (Check all that apply)

Multi‑Factor Authentication (MFA) for remote access Endpoint Detection & Response (EDR) Encryption at Rest Encryption in Transit

Regular Automated Backups Offline / Immutable Backups Formal Patch Management Program Regular Penetration Testing

In place and tested within last 12 months If yes, provide last test date:

Yes No

5. Coverage Options

Select coverages desired and specify sublimits or waiting periods where applicable.

Incident Response & Forensic Expenses — Sublimit: $

Business Interruption & Extra Expense — Waiting Period: Sublimit: $

Data Breach Notification & Credit Monitoring — Sublimit: $

Regulatory Defense & Fines (where insurable) — Sublimit: $

Cyber Extortion / Ransom Payments — Sublimit: $ Payment Approval Required:

6. Exclusions & Limits

The policy will include customary exclusions including, but not limited to: (a) war, invasion, or hostilities of a foreign power; (b) intentional acts or knowingly unlawful acts by an insured; (c) bodily injury and property damage covered by other liability policies; (d) prior knowledge of a security breach or a circumstance reasonably expected to give rise to a claim that was not disclosed on this application; (e) punitive damages to the extent uninsurable by law; and (f) contractual liability arising from assumed contractual obligations except where covered by written endorsement. Insured must maintain reasonable security controls as represented herein; failure to maintain controls may void coverage for losses resulting from the failure.

7. Payee / Beneficiary for Claim Payments

Designate the party to receive claim payments if different from the named insured.

8. Declarations, Certifications and Authorizations

The undersigned authorized representative declares that to the best of their knowledge the statements contained in this application are true, complete and are material to the acceptance of the risk. The applicant understands that any omission, misstatement or concealment of fact may be grounds for rescission or denial of coverage for any claim arising from such omission or misrepresentation. The applicant further agrees that this application, together with any attachments, shall form the basis of the policy and may be attached to and made part of the policy if issued.

Authorization: The applicant authorizes the insurer to obtain loss history, claim information and security assessment reports from prior insurers and third‑party administrators, and to disclose underwriting and claim information to reinsurers, auditors, and regulators as required. The applicant consents to the insurer performing a pre‑binding security assessment and verifying representations contained in this application at any time.

Warranty of Information Security: Where the applicant has affirmed the existence of specific security controls, such affirmations constitute warranties upon which coverage will be conditioned. The insurer reserves the right to require corrective action prior to binding coverage and to exclude losses arising from a failure to implement reasonable corrective measures as directed.

Subrogation and Recovery: In the event of payment under the policy, the insurer shall be subrogated to the insured's rights of recovery against any third party to the extent of such payment. The insured agrees to cooperate with the insurer in preserving and perfecting such rights.

9. Fraud Warning & Acknowledgement

Any person who knowingly presents a false or fraudulent claim for payment of a loss or who knowingly presents false information in an application for insurance may be subject to civil and criminal penalties under applicable law. The applicant acknowledges that they have read and understood the declarations and authorizations contained in this application and that the information supplied is true and complete.

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