Application – Cyber Security Liability

Section I - General Information

Name of Applicant*

Address*

City*

State*

Zip*

Email*

Phone*

Website

Nature of Operations*

Annual Revenue ($USD)*

Number of Clients*

Section II - Loss Experience

During the past three (3) years have you sustained any loses due to unauthorized access, unauthorized use, virus, denial of service attack, data breach, data theft, fraud, electronic vandalism, sabotage or other similar electronic security events?*

Yes
No

During the past three (3) years, has anyone alleged that you were responsible for damage to their comuputer system(s) arising out of the operation of your computer system(s)?*

Yes
No

During the past three (3) years, has anyone made a demand, claim, complaint, or filed a lawsuit against you alleging invasion of, or interference with rights of privacy, or the inappropriate disclosure of personally identifiable information (PII)?*

Yes
No

During the past three (3) years, have you been the subject of an investigation or action by any regulatory or administrative agency for privacy-related violations?*

Yes
No

Section III - Risk Controls

Do you have a firewall?*

Yes
No

Do you have a virus protection program in place?*

Yes
No

Do you have a designated individual responsible for information security?*

Yes
No

Do you have a written privacy or security policy?*

Yes
No

Do you control access to your computer systems?*

Yes
No

Do you have a program or procedure in place to test your security/privacy controls?*

Yes
No

Do you encrypt confidential client information stored on laptops, mobile devices, or other storage media??*

Yes
No

FRAUD STATEMENTS AND SIGNATURE SECTIONS

The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company* in quoting and issuing the policy. If any of the information in this Application changes prior to the effective date of the policy, the Applicant will notify the company of such changes and the Company may modify or withdraw the quote or binder.

The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.

*Company refers to Tokio Marine Specialty Insurance Company

FRAUD NOTICE STATEMENTS

APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AGENCIES.

Name (Print)*

Title*

Date*

Signature