Cyber Liability Quote Form

Contact Name*

Company Name*

Email Address*

Phone Number*

Address*

Street Address Address Line 2 County Post Code

Business Description*

Total Turnover*

No. of Employees*

Statement of fact for Cyber & Privacy Liability Coverage

Do you and your subsidiaries comply with the requirements details in the statement of fact below?

You have anti-virus software installed and enabled on all desktops, laptops and servers (excluding database servers) and is updated on a regular basis.*

You have firewalls installed on all external gateways.*

You take regular backups (at least weekly) of all critical data and store the same offsite or in a fire-proof safe, or you outsourced service provider meets this requirement.*

If you store medical records or patient data, do you comply with the following?*

You ensure that all patient data transmitted over open networks and/or stored on portable devices is encrypted.

If you process or store credit card information (where this is not outsourced to a third party that accepts full responsibility for PCI compliance), do you comply with the following?*

You have been certified as being PCI compliant within the last 12 months, or have successfully completed a self-assessment audit.

Claims Information

In regards to claims or circumstances that could give rise to a claim, are the below statements true?

After full inquiry, you are not aware of any circumstances, complaints, claims, loss, penalties or fines levied against you in the last 5 years, in relation to the risks that this application relates to.*

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You are not aware of any circumstances or complaints against you in relation to data protection or security, or any actual security violations or security breaches either currently or in the past 5 years.*

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