Centerpoint Insurance Group Cyber Security Liability/Privacy Liability Non-Binding Indication Form

SECTION I - GENERAL INFORMATION

Name of Applicant*

First Last

Address of Applicant*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

Phone*

Nature of operations insured*

Annual Revenue $*

Number of clients*

SECTION II - RISK CONTROLS

Do 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*

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.

Cyber Security Liability/Privacy Liability Non-Binding Indication Form

Cyber Security Liability/Privacy Liability Non-Binding Premium Indication Form

SECTION I - GENERAL INFORMATION

SECTION II - RISK CONTROLS