1Company Details2Cover Required3Security4Data Records Company Name – please include all companies requiring cover*Correspondence Address*Company Start Date* DD slash MM slash YYYY Contact Email*Contact Name*Phone number*Company Website Address*Who is your current Cyber Insurance provider?*Please SelectNo Current InsuranceAIGAvivaAXABeazleyCFCCoalitionCowbellCyber+InsureHiscoxHSBLloydsNIGPenZurichNot ListedDate Cover required from* DD slash MM slash YYYY Business Description – please provide full details*Has Any Director, officer or business partner in either personal or business capacity ever been:* Refused insurance, insurance proposal declined, had insurance cancelled, any renewal refused or any special conditions imposed? Ever Defaulted on any Instalment Agreement? Ever been convicted of a Criminal Offence? Ever been subject to a CCJ or equivalent, satisfied or otherwise? Ever been Declared Bankrupt? Ever been a Director of a liquidated company or disqualified as a director? Prosecuted for breach of any statutory requirement relating to Health & Safety If yes please check the box and provide detailsCompany Annual Revenue*Largest Client Contract* Cyber Liability LimitLimit of Indemnity*Choose an item£100,000£250,000£500,000£1,000,000£1.500,000£2,000,000£5,000,000£10,000,000£15,000,000Basis of cover*Choose an itemAny One ClaimAggregateCyber Crime Limit*Choose an item£50,000£100,000£250,000£500,000£1,000,000Additional CoversMultimedia Liability Cover requiredProfessional Indemnity Cover requiredComputer Cover (All Risks) Please click the checkbox's which are applicable.* All Computer devices, laptops & Mobile phones have encryption (passwords) IT Professional Employed to Set up Computer Systems and maintain them Multi-Factor Authentication active on all emails accounts & banking software Antivirus and Firewalls kept up to date on a weekly basis All System Updates are completed on a regular basis (monthly latest) Remote desktop services used If Yes do you use a Virtual Private Network Annual Simulated Phishing attacks to train staff Email Filtering Active Web Content Filtering Active Administration Rights restricted for non IT Staff Penetration testing deployed Are your Databases Encrypted Vulnerability Scans regularly undertaken Asset Inventory stored DNS Filtering active Incident Response plan in place Data Loss Prevention Software in place Endpoint protection installed Dual ControlsCall to check bank details, and instructions on large payments* Yes No Number of Data Records (Client’s)*Choose an itemLess than 10,000Less than 20,000Less than 50,000Less than 100,000Over 100,000Do you store Sensitive data for individuals who are not your employees* Yes No If yes what type of Sensitive Client data keptChoose an itemRacial or Ethnic OrginPolitical or Religious Affliation or BeliefMedical, Genetic or BiometricSexual OrientationNumber of sensitive date records*Card Payment Records Stored* Yes No Number of Card Payments stored if relevantComply with the PCII DSS* Yes No PCI Merchant Level*Choose an itemLevel 1Level 2Level 3Level 4Name of managed Service provider*Number of Servers on your network*Number of computer devices on the network*Annual IT Budget*Please click the checkbox's which are applicable to you* Cloud based storage used Physical Back up Local Storage Are backups done on a regular basisChoose an itemDailyWeeklyMonthlyDo you outsource your IT Infrastructure* Yes No If yes please list who to and what they doIs your website created & maintained by IT professionals* Yes No Do you remove & check for potentially defamatory content or content that could infringe on intellectual property rights of a Third Party* Yes No Please list any claims or losses – Date, Amount and description