Cyber Liability Insurance

Application Form

Use this form to contact us and discuss your need for Cyber/Privacy Breach insurance

Complete this application and submit to us
to request a quote for Cyber/Privacy Breach insurance.

1-800-566-6314 cyberliability@palladiuminsurance.ca

CyberPro Network Application

Please answer all the questions on this form. Before any question is answered please carefully read the declaration at the end of the application form, which you are required to sign. Underwriters will rely on the statements that you make on this form. In this context, ANY INSURANCE COVERAGE THAT MAY BE ISSUED BASED UPON THIS FORM WILL BE VOID IF THE FORM CONTAINS FALSEHOODS, MISREPRESENTATIONS, OR OMISSIONS. PLEASE TAKE CARE IN FILLING OUT THIS FORM.

You may provide any further additional information by means of a separate attachment if necessary.

General Information

a. Your Full Name*

b. Address*

c. Website*

Phone*

Email*

d. Annual gross revenue / turnover

Last Year*

Current Year*

Next Year Est.*

e. Approximately how many PII’s are retained within your computer network, databases and records? (PII is defined as a personally identifiable record on an individual that can be used to identify, contact or locate a single individual)*

f. Identify the type of PII retained on your network

1. Payment card data*YesNo

2. Healthcare data*YesNo

3. Other PII*YesNo

If you have answered ‘Yes’ to f3. please provide details of the nature of this PII.

g. Details of your main business operations

h. Current number of employees

Network Information

a. Do you have a business continuity plan in force to avoid business interruption due to systems failure?*YesNo

b. Are all portable and mobile devices encrypted?*YesNo

c. If you have answered ‘No’ to question b, please detail the type and how much PII is stored on portable media devices and how it is protected in the absence of encryption.

d. Do you have firewalls and automatically updating antivirus software in force across your network?*YesNo

e. Is all sensitive and confidential information stored on your databases, servers and data files encrypted?*YesNo

f. Is all information held in a physical form disposed of or recycled by confidential and secure methods?*YesNo

g. Do you have a privacy policy on your website which has been legally reviewed and includes a statement advising users as to how any information collected will be used and for what purposes?*YesNo

h. Do you have a process in force to obtain a legal review of all media content and advertising materials prior to release?*YesNo

i. Please confirm up-to-date compliance with relevant regulatory and industry framework (eg. Gramm-Leach Bliley Act, Health Insurance, Portability & Accountability Act (HIPAA), Payment Card Industry (PCI), Data Security Standard, CAN-SPAM Act, TCPA or similar.*YesNo

Historical Information

During the last three years have you:

a. Sustained any unscheduled or unintentional network outage, intrusion, corruption or loss of data?*YesNo

b. Received notice or become aware of any privacy violations or that any data or personally identifiable information has become compromised?*YesNo

c. Been subject to any disciplinary action, regulatory action, or investigation by any governmental, regulatory or administrative agency?*YesNo

d. Received any injunction(s), lawsuit(s), fine(s), penalty(s) or sanction(s)?*YesNo

e. Become aware of any circumstance or incident that could be reasonably anticipated to give rise to a claim against the type of insurance(s) being requested in this application?*YesNo

If ‘Yes’ to any questions within this section, please provide full details:

Data Protection

By accepting this insurance you consent to Ascent Underwriting using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example health information or criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities.

Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and in compliance with relevant Data Protection legislation. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.

IMPORTANT – CyberPro Policy Statement of Fact

By accepting this insurance you confirm that the facts contained in the proposal form are true. These statements, and all information you or anyone on your behalf provided before we agree to insure you, are incorporated into and form the basis of your policy. If anything in these statements is not correct, we will be entitled to treat this insurance as if it had never existed. You should keep this Statement of Fact and a copy of the completed proposal form for your records.

This application must be signed by the applicant. Signing this form does not bind the company to complete the insurance. With reference to risks being applied for in the United States, please note that in certain states, any person who knowingly and with intent to defraud any insurance company or other person submits an application for insurance containing any false information, or conceals the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

The undersigned is an authorized principal, partner, director, risk manager, or employee of the applicant and certifies that reasonable inquiry has been made to obtain the answers herein which are true, correct and complete to the best of his/her knowledge and belief. Such reasonable inquiry includes all necessary inquiries to fellow principals, partners, directors, risk managers, or employees to enable you to answer the questions accurately.

Name*

Position*

Signature*

Date*

Additional Notes