Insurance Quote Exc Cyber

Insurance Quote — Excluding Cyber

Applicant / Insured Information

Applicant Name:

Individual Corporation LLC Partnership Other

Date of Birth / Incorporation Date:

Proposed Policy Details

Policy Type:

Proposed Effective Date:     Proposed Expiration Date:

Coverage Options (select applicable)

General Liability

Property Damage

Business Interruption

Professional Liability / E&O

Cyber Coverage: Requested     Cyber Coverage Excluded from this Quote:

Pollution Liability:     Other (describe):

Exclusions and Notable Provisions

The following exclusion is integral to this quote and will be a condition of any policy issued pursuant to this quote. The Insurer expressly declines coverage for cyber-related loss as follows:

Cyber Exclusion: Coverage under any policy issued on the basis of this quote does not extend to any loss, damage, liability, cost, expense, or regulatory action directly or indirectly caused by, resulting from, arising out of, contributed to by, or in any way related to any electronic data, computer system, network, software, firmware, microcode, or hardware, including but not limited to: unauthorized access, data breach, malware, ransomware, denial of service, phishing attacks, extortion, any criminal act executed via electronic means, or the failure, malfunction, or disruption of electronic systems. This exclusion applies regardless of any other cause or event that contributes concurrently or in any sequence to the loss.

Additional Standard Exclusions (check if applicable to quote):

War and nuclear hazards Intentional acts / fraud by the insured Pollution and contamination where excluded under specific coverage parts

Underwriting Questions

Yes No

Financial statements Loss runs Corporate formation documents

Beneficiary / Loss Payee (if applicable)

Beneficiary Name:

Relationship to Insured:     Percentage of Proceeds:

Declaration and Certification

I, the undersigned, declare that the statements and particulars contained in this form are true, complete, and correctly recorded to the best of my knowledge and belief. I acknowledge that this document is a quotation only and does not bind the insurer to provide coverage until a policy is issued and the insurer has received any required premium. I understand and accept that the cyber exclusion set forth herein will form part of the policy terms and conditions if a policy is issued pursuant to this quote. I further certify that I have disclosed all material facts known to me that could influence underwriting or acceptance of risk.

I understand that any omission or misrepresentation of fact may be grounds for denial of coverage or rescission of any policy issued. I authorize the insurer to obtain and exchange information necessary for underwriting and claims handling with other insurers and relevant third parties where permitted by law.

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