Insurance Excess Cyber Quote

INSURANCE EXCESS CYBER QUOTE

Applicant / Insured

Policy Summary / Quote Terms

Policy Type:

Policy Period: From To (both dates inclusive)

Quote Valid Until: Layer Number:

Coverage Options (select as applicable)

First-Party: Data Breach Response and Notification Costs

Business Interruption and Extra Expense

Cyber Extortion / Ransom Payments (subject to conditions)

Regulatory Defense, Fines and Penalties (where insurable by law)

Third-Party Liability (privacy liability / network security)

Forensic Investigation Costs

Crisis Management and Public Relations Expenses

Underwriting & Risk Information

Prior Claims / Incidents

Have you had any cyber incidents, claim or breach in the past 5 years? Yes No

Exclusions (Representative)

This quotation is offered subject to a policy form that will exclude, among other matters, loss or liability arising from:

• Intentional, fraudulent or criminal acts of the insured or insured persons not disclosed to the insurer;
• War, hostilities, invasion, insurrection, terrorism as defined in the policy wording where excluded;
• Bodily injury or property damage (except to the extent specifically endorsed);
• Prior acts or known circumstances not disclosed at the time of proposal;
• Contractual liability assumed by the insured beyond indemnity obligations existing at law unless expressly agreed;
• Fines and penalties that are uninsurable under applicable law (subject to policy wording).

Beneficiary / Payee Designation (Optional)

Designated Payee for Claim Proceeds (if applicable):

Documentation Checklist

Required documentation to bind coverage (subject to underwriter review):

Completed application signed by applicant

Prior loss runs / incident history

External/internal security assessment report

Evidence of underlying coverages and limits

Conditions, Limitations and Declarations

This quotation represents the insurer's indicative terms and premium for the coverage requested. It is non-binding and subject to: (a) receipt and satisfactory review of all requested documentation; (b) verification of all statements and representations; and (c) underwriting approval and issuance of a policy form. Coverage, if bound, will be governed by the policy wording and endorsements issued at binding.

The insured warrants that all information supplied in this form and in any accompanying documents is true, complete and not misleading. Material misstatement, concealment, or fraud may render any subsequent policy null and void or permit the insurer to deny coverage for matters related to such misrepresentation. The insured shall cooperate with the insurer in any investigation, loss control, and claims handling process and shall not incur expense, assume obligation, or admit liability without the insurer's prior written consent.

This quote is subject to policy terms including but not limited to subrogation rights, contribution from other insurers, and retention requirements. Any payment of premium, taxes or fees as required for binding will be specified by the insurer at the time of acceptance.

Attestation

By signing below the undersigned attests, on behalf of the insured, that the information provided in this Insurance Excess Cyber Quote form is accurate to the best of their knowledge, that they are authorized to request this quote and to provide the information herein, and that they understand this document constitutes an offer request and not a binding insurance contract. Acceptance of this quotation is subject to underwriting review and issuance of policy documentation.

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