Cyber Security Liability/Privacy Liability Non-Binding Indication Form Cyber Security Liability/Privacy Liability Non-Binding Premium Indication Form SECTION I - GENERAL INFORMATIONName of Applicant* First Last Address of Applicant* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Website Phone*Nature of operations insured* Annual Revenue $*< $50,000$50,000 - $100,000$100,000 - $250,000Number of clients*5 or less6-1516-25SECTION II - RISK CONTROLSDo you have a firewall?* Yes No Do you have a virus protection program in place?* Yes No Do you have a person responsible for information security?* Yes No Do you outsource a critical part of your internal network/computer system or internet access/presence to others?* Yes No If yes please explain:Do you have a written privacy or security policy?* Yes No Do you control access to your computer systems?* Yes No Does your hiring process include criminal background checks?* Yes No Have you ever experience a privacy breach or security breach?* Yes No (If yes, please contact our office)Do you have a program in place to test your security/privacy controls?* Yes No Including the services of your vendors?* Yes No 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 If yes, is the information encrypted?* Yes No Types of Personally Identifiable Information held (check all that apply):* Social Security Numbers Drivers Licenses Bank Account Details Personal Health Information Credit Card Numbers Other - Please specify: Other Personally Identifiable Information held:Representative or Authorized Agent (Please Print/Type)* Date* MM slash DD slash YYYY Representative or Authorized Agent E-mail Address* Any offer of insurance coverage resulting from the submission of this non-binding premium estimate sheet will be an estimate of premium costs, forms, terms and conditions. To secure a bindable quotation, it will be necessary to complete a Cyber Security Liability Insurance application and submit all required attachments. For more information regarding this product or to download the application and other forms, please visit our website at www.phly.com/products/cybersecurity.aspx.
