Cyber Loss and Liability Insurance Application

Name
Contact Information
Address
Name
DBA
Name of Person Completing Application
Email Address
Type of Business
Principal Address
Primary Web Address
Are there any additional entities? Please list.
Additional Entity #2 Nature of Operations
Additional Entity #2 Relationship to Company
Year Business Started
Total Number of Employees (please include all full, part, time seasonal, leased, etc.)
Total Assets as of Most Recent Fiscal Year End
Total Gross Revenues Last Fiscal Year
Anticipated Revenues This Fiscal Year
Anticipated Revenues Next Fiscal Year
Percentage of Annual Revenues Estimated to be attributable to E-Commerce/Online Sales (%)
Has the Company experienced Privacy Incident and/or claims within the last three years? (Y or N)
Has the Company experienced Media Incident and/or claims within the last three years? (Y or N)
Has the Company experienced Cyber Crime Incident within the last three years? (Y or N)
Has the Company experienced Network Incident and/or claims within the last three years? (Y or N)
Do you presently purchase Cyber Risk Insurance? (Y or N) Please email a copy to agency@erm-ins.com
Cyber Risk Liability Insurance Limits Requested
Are you aware of any fact, circumstance, or situation involving the Company that you have reason to believe will cause a Privacy Incident, Network Security Incident, Media Incident, Cyber Crime Incident, or Claim? (Y or N)
How frequently do you test your ability to restore from back ups?
Do you outsource your web hosting? (Y or N)
Are you compliant with the Payment Card Industry Data Security Standard (PCI-DSS)?
Additional Comments