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Company Name

ALL ONLINE ASSETS to be covered and associated emails (.com, .net, .org, etc.)

Primary Insured Email

IT Email Contact

Business Address

Industry Type

Number of Employees

Gross Revenue (Required to insure any 1st party business interruption and determine max face amounts)

Net Profits (Required to insure any 1st party business interruption)

Within the last 3 years has entity suffered any cyber incidents resulting in a claim in excess of $25,000? Within the last 3 years has entity suffered any cyber incidents resulting in a claim in excess of $25,000? Yes No

If 'yes', please describe

Did they already suspect? Did they already suspect? Yes No

Does Named Insured implement encryption on all accessible devices? Does Named Insured implement encryption on all accessible devices? Yes No Sometimes

Does Named Insured collect, process, store, transmit, or have access to any Payment Card Information (PCI), Personally Identifiable Information (PII), or Protected Health Information (PHI) other than employees of Named Insured? Does Named Insured collect, process, store, transmit, or have access to any Payment Card Information (PCI), Personally Identifiable Information (PII), or Protected Health Information (PHI) other than employees of Named Insured? Yes No

What is the estimated annual volume of payment card transactions (credit cards, debit cards, etc.)?

How many PII or PHI records does Named Insured collect, process, store, transmit, or have access to?

Do you enforce Multi-Factor Authentication (MFA) on: Email, VPN’s, RDP, RDPWeb, RD Gateway or other remote access, network clouds or other privileged user accounts? Do you enforce Multi-Factor Authentication (MFA) on: Email, VPN’s, RDP, RDPWeb, RD Gateway or other remote access, network clouds or other privileged user accounts? Yes No ON ADMINISTRATIVE ACCOUNTS AND ALL CLOUD SERVICES WHERE SUPPORTED

Does Named Insured maintain at least weekly backups of all sensitive or otherwise critical data and all critical business systems offline or on a separate network? Does Named Insured maintain at least weekly backups of all sensitive or otherwise critical data and all critical business systems offline or on a separate network? Yes No N/A

Does Named Insured require a secondary means of communication to validate the authenticity of funds transfers (ACH, wire, etc.) requests before processing a request in excess of $25,000? Does Named Insured require a secondary means of communication to validate the authenticity of funds transfers (ACH, wire, etc.) requests before processing a request in excess of $25,000? Yes No

Would you verify any large value transaction prior too and or in addition to processing it? Would you verify any large value transaction prior too and or in addition to processing it? Yes No

Within the last 3 years has Named Insured been subject to any complaints concerning the content of its website, advertising materials, social media, or other publications? (copyright Infringements, etc..) Within the last 3 years has Named Insured been subject to any complaints concerning the content of its website, advertising materials, social media, or other publications? (copyright Infringements, etc..) Yes No

Does Named Insured enforce procedures to remove content (including third party content) that may infringe or violate any intellectual property or privacy right? Does Named Insured enforce procedures to remove content (including third party content) that may infringe or violate any intellectual property or privacy right? Yes No

Would you take it down or ask too if aware? Would you take it down or ask too if aware? Yes No

Are you a Technology provider? (IT, MSP) Are you a Technology provider? (IT, MSP) yes no

Within the last 3 years has Named Insured been subject to a dispute or claim arising out of a technology error or omission in excess of $25,000? Within the last 3 years has Named Insured been subject to a dispute or claim arising out of a technology error or omission in excess of $25,000? Yes No

Is Named Insured operating as a managed service provider (MSP) Is Named Insured operating as a managed service provider (MSP) Yes No

If the Named Insured participates directly in or sells technology products/services designed for any of the following industries, please select all that apply If the Named Insured participates directly in or sells technology products/services designed for any of the following industries, please select all that apply Cannabis Internet of Things Financial Services Healthcare Blockchain Automotive Aviation Military/Defense Gambling Cryptocurrency Payment Processing Adult Entertainment Point of Sale (POS) Software/Hardware/Reseller Professional Services (Legal, Medical, A&E, or other licensed professional services)

How often are Named Insured’s services provided by written agreement or contract?

Identify the standard risk mitigating clauses or methods contained within Named Insured’s agreements or contracts Identify the standard risk mitigating clauses or methods contained within Named Insured’s agreements or contracts Customer acceptance / Final sign Off Disclaimer of warranties Hold harmless agreements that benefit named insured Limitation of liability Exclusion of consequential damages Indemnification clause Binding mandatory arbitration Project phases / milestones