Cyber Liability Insurance Application

GENERAL INFORMATION

Full Name of Applicant:

Principal Address:

Nature of Business (Industry):

Primary Corporate Website Address:

Total Employee Count:

Annual Gross Revenues – Most recent 12 months:

Projected Next 12 Months:

Please attach a list of all subsidiaries, affiliated companies or entities owned by the Applicant Please describe (1) the nature of operations of each such subsidiary, affiliated company or entity, (2) its relationship to the Applicant and (3) the percentage of ownership by the Applicant

Do you engage in any of the following business activities? (select all that apply)

Within the Applicant’s organization, who is responsible for network security?

Name: *

Title: *

Email Address: *

Phone Number *

DATA COLLECTION INFORMATION

Estimate number of unique personally identifiable records maintained (including records stored by third-party providers)

PII includes any information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other personal or identifying information that is linked or linkable to a specific individual.

Do you deal with protected health information as defined by HIPAA?

Yes
No

If “Yes”, do you have procedures and audit practices in place to ensure compliance under the rules and regulations of HIPAA, including the encryption of any electronically transmitted record

Do you deal with biometric information or data such as fingerprints, voiceprints, facial, hand iris or retinal scans, DNA, or any other biological, physical or behavioral characteristics that can be used to uniquely identify a person?

Yes
No

transfer as relationship

If “Yes”, have you confirmed compliance with applicable federal, state, local and foreign laws?

Do you accept credit or debit card payments

Yes
No

If applicable, do you deploy either end-to-end or point-to-point encryption technology on all of you point of sale terminals?

Yes
No

SECURITY CONTROLS

Do you require multi-factor authentication for:

All remote access to the network including any remote desktop protocol connections?

Yes
No

All Web based email accounts?

Yes
No

Local and remote access to privileged user/network administrator accounts?

Yes
No

Internal and external access to cloud based back-ups?

Yes
No

Do you use a commercially available and regularly updated firewall and anti-virus protection system for all your computer systems?

Yes
No

Do you use intrusion detection software to detect unauthorized access to your computer systems?

Yes
No

Do you filter or scan incoming emails for potentially malicious attachments and links?

Yes
No

If “Yes”, do you have the capability to automatically detonate and evaluate attachments in a sandbox to determine if they are malicious prior to delivery to the end-user?

Are you compliant with the Payment Card Industry (PCI) Data Security Standards?

Yes
No

Do you implement SPF, DKIM and DMRAC to protect against phishing messages?

Yes
No

Do you use Office 365?

Yes
No

If “Yes”, do you use the Office 365 Advanced Threat Protection add-on?

Do you regularly monitor security vulnerabilities and appropriately patch and upgrade systems & applications?

Yes
No

Apply security patches within 30 days of release?

Yes
No

Is your critical business data backed-up and stored in a secure location?

Yes
No

if yes, how often:

Does the backup solution include all the following characteristics: kept in a cloud service protected by MFA, has been tested in the last 6 months, and can be used to restore essential network functions within 3 days of a widespread malware or ransomware attack?

Yes
No

Do you use 3-2-1 backup procedures? Two different media storage types and one copy off site for disaster recovery?

Yes
No

Do you test the successful restoration and recovery of key server configurations and date from backups?

Yes
No

Do you use a cloud provider to store data or host applications?

Yes
No

If “Yes”, please provide the name of the cloud provider:

Do you encrypt private or sensitive information stored on the network or cloud?

Yes
No

Do you encrypt private or sensitive information stored on mobile devices?

Yes
No

Do you use an endpoint detection and response (EDR) tool that includes centralized monitoring and logging of all endpoint activity across your enterprise?

Yes
No

If “Yes”, please provide the name of your EDR provider:

Are employees required to undergo annual security training?

Yes
No

Do you have controls in place which require all fund and wire transfers over $25,000 to be authorized and verified by at least two employees prior to execution?

Yes
No

Does the applicant provide data processing, storage, hosting, or Managed Security Services Provider (MSSP) services to third parties?

Yes
No

Has there been a vulnerability assessment in the past 18 months?

Yes
No

Do you have a tested business continuity/disaster recovery program in place?

Yes
No

LOSS/CLAIMS INFORMATION

In the past 3 years, has the Applicant or any other person or organization proposed for this insurance:

Is the Applicant aware of any fact, circumstance, situation, event, or Wrongful Act which reasonably could give rise to a Cyber Event, Loss, or a Claim being made against them that would fall within the scope of the Policy for which the Applicant is applying?

Yes
No

In the past 3 years, has any service provider with access to your network or computer system(s) sustained an unscheduled network outage or interruption lasting longer than 4 hours?

Yes
No

If “Yes”, did you experience an interruption in business as a result of such outage of interruption?

If answered yes to any of the above, please attach full details for each yes answer on a separate attachment.

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service@monteleoneins.com | 631-544-4000

Cyber Liability Insurance Application

GENERAL INFORMATION

DATA COLLECTION INFORMATION

SECURITY CONTROLS

LOSS/CLAIMS INFORMATION

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