Continental Brokers -

Cyber Liability Application

THIS APPLICATION IS FOR CLAIMS-MADE AND REPORTED COVERAGE. CLAIMS-MADE AND REPORTED COVERAGE APPLIES ONLY TO CLAIMS THAT ARE FIRST MADE AND REPORTED DURING THE POLICY PERIOD OR EXTENDED REPORTING PERIOD, IF PURCHASED. THE LIMIT OF LIABILITY AVAILABLE TO PAY DAMAGES WILL BE REDUCED AND MAY BE EXHAUSTED BY CLAIMS EXPENSES. FURTHERMORE, CLAIMS EXPENSES WILL BE APPLIED AGAINST THE RETENTION.

Company Name:

Website Domain:

Address 1:

Address 2:

City, State Zip:

Phone:

Email:

Industry:

Number of Employees:

Revenue:

$

Expected revenue for the next 12 months

Gross Profit\Net Revenue:

$

Policy Start Date:

Effective date of the policy when issued. Maximum is +60 days.

Within the last 3 years has Named Insured suffered any cyber incidents resulting in a claim in excess of $25,000?

No

Yes

Explain:

Is Named Insured aware of any circumstances that could give rise to a claim under this insurance policy?

No

Yes

Explain:

Does Named Insured implement encryption on laptop computers, desktop computers, and other portable media devices?

No

Yes

Sometimes

Does Named Insured collect, process, store, transmit, or have access to any Payment Card Information (PCI), Personally Identifiable Information (PII), or Protected Health Information (PHI) other than employees of (insured)?

No

Yes