Cyber Risks Cover Application

Your Details

Your Name:(required)

Company Name:(required)

Contact Telephone Number:(required)

Email Address:(required)

Insured Details

Insured Company:(required)

Trade/Profession:(required)

Address:(required)

Postcode:(required)

Country:(required)

Total Revenue:(required)

Please enter the total revenue for the business.

Percentage of e-commerce business:(required)

The business can confirm that:

All of the Partners, Directors, Principals, and Consultants after having made full enquiries, including of all staff, are NOT aware of any event that has or could have given rise to a loss, claim or circumstance under a cyber / privacy policy, including but not limited to any hacking incident, virus or malicious code attack, cyber extortion attempt, breach of confidential data, wrongful disclosure of personal data or interference with rights of privacy (required)

Yes

No income is derived from the USA (required)

Yes

It is not a custodian or manager of client funds?(required)

Yes

That the statements and particulars in this proposal are true and complete and no material facts have been mis-stated or suppressed. It undertakes to inform Underwriters of any material alteration or addition to these statements or particulars which occurs before any contract of insurance based on this declaration is effected.(required)

Yes

If the answer to any of the preceding questions is “No”, please
specify the reasons and provide details below:

Cover Details

Limit of Indemnity Required:(required)

Other

Cover Start Date:(required)

This field should be left blank

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