APPLICANT INFORMATION:

Applicant/Firm Name

DBA

Address

Address (cont)

City

State

ZIP

email Address

Phone Number

Website URL

1. Nature of Operation of Insured

2. Annual Revenue

3. Do you have a firewall?

Yes
No

4. Do you have a virus protection program in place?

Yes
No

5. Do you outsource a critical part of your internal network/computer system of internet access/presence to others? If yes, please explain

Yes
No

If yes, please explain

6. Do you have a written privacy or security policy?

Yes
No

7. Do you control access to your computer systems?

Yes
No

8. Does your hiring process include criminal background checks?

Yes
No

9. Have you ever experienced a privacy or security breach? If yes, please explain

Yes
No

If yes, please explain

10. Do you have a program in place to test your security/privacy controls? Including the services of your venders?

Yes
No

11a. Do you allow employees to download Personally Identifiable information of customers or confidential information in your care belonging to third parties onto laptops or other storage media?

Yes
No

11b. If yes, is the information encrypted?

Yes
No

12. Types of Personally Identifiable Information held (check all that apply)

SSS
Bank Account Details
Credit Card Numbers
Drivers Licenses
Personal Health Information
Other

If "Other", please explain

This non-binding premium indication form is for a “non-binding premium estimate” for the prospective insured. A contract of insurance cannot be confirmed and the resulting indication is subject to change.