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Cyber
Cyber Form
Insured Name
ABN
Email
Phone Number
Director(s) Name(s)
Business Description (What do you do?)
Insured Address
Address Line 1
Address Line 2
City
State
Area Code
Insured Entity Type
Sole Trader
Partnership
Public Listed Company
Not For Profit
Private Company (Pty Ltd)
Is the Policyholder a subsidiary, franchisee or smaller company of a larger group?
- Select -
Yes
No
Insureds Website Address
Director/Partner Name
Director/Partner Name
Director/Partner Name
Date of Birth
Date of Birth
Date of Birth
Qualifications
Qualifications
Qualifications
Date Qualified
Date Qualified
Date Qualified
Length of Service
Length of Service
Length of Service
Are you domiciled in Australia with no subsidiaries outside Australia or New Zealand
- Select -
Yes
No
If No please advise where else you operate
The Gross Turnover Last Financial Year in Australia
The Gross Turnover Last Financial Year in USA/Canada
The Gross Turnover Last Financial Year Elsewhere
The Gross Turnover Current Financial Year in Australia
The Gross Turnover Current Financial Year in USA/Canada
The Gross Turnover Current Financial Year Elsewhere
The Gross Turnover Coming Financial Year in Australia
The Gross Turnover Coming Financial Year Elsewhere
The Gross Turnover Coming Financial Year in USA/Canada
Confirm which State/Territory You Operate In
NSW
VIC
QLD
SA
WA
TAS
NT
ACT
Do you Import or Export?
- Select -
Yes
No
Do you assume liability or contract in additional exposure?
- Select -
Yes
No
Do all subcontractors carry their own Public & Products Liability insurance?
- Select -
Yes
No
Number of Full Time Employees
Number of Part Time or Casual Employees
Do you perform work for the Defence industry or Federal Government or are you a member of the Defence Industry Security Program (DISP)?
- Select -
Yes
No
Are all mobile devices (such as laptops, tablets, smartphones and memory stick) password protected?
- Select -
Yes
No
Do you enforce a restricted access management policy for administrator rights and critical resources?
- Select -
Yes
No
Are staff trained on cyber security?
- Select -
Yes
No
How frequently does the Policyholder provide security awareness training to their employees?
- Select -
Never
Annually
Quarterly
Monthly
Other
How often do you back up sensitive, confidential, critical or valuable data?
Have you implemented a critical security patch management process for your IT systems
Yes
No
Is Multi-Factor Authentication (MFA*) required to access the following systems/platforms/services?
Yes
No
Is Multi-Factor Authentication (MFA*) required to access the following systems/platforms/services?
Yes
No
All remote access to the network?
Yes
No
Web-based email
Yes
No
Admin / Privileged Service Accounts
Yes
No
Cloud resources, including backups?
Yes
No
How frequently do you take regular backups of critical data and systems?
- Select -
Daily
Weekly
Monthly
Greater
Do you keep a copy of critical backups offline, segregated from and inaccessible to your network?
Yes
No
How do you back up your data?
Is Data Encrypted?
- Select -
Yes
No
Do you have MFA Protection?
- Select -
Yes
No
Uses Immutable Technology
- Select -
Yes
No
Do you have any of the following in place?
A data breach response plan
A business continuity plan / disaster recovery plan which takes cyber perils into consideration
An IT security policy / framework
Is the Disaster Recovery Plan or Business Continuity Plan tested annually?
NA
Yes
No
After how long will your business be impacted by a loss to your site/systems?
0-6 hours
6-12 hours
12-24 hours
Above 24 hours
After enquiry, within the past 5 years, is the Policyholder aware of any losses, claims, circumstances, cyber events, privacy breaches, regulatory investigations, crime or social engineering incidents which have impacted, or could adversely impact your business or give rise to a claim under a cyber policy?
Yes
No
Have you had any unforeseen down time to your website or IT network of more than 8 hours?
Yes
No
Do You Want Optional Cover For Criminal Financial Loss (Incl. Cyber Theft, Telephone Phreaking & Cryptojacking)?
Yes
No
Do you want Optional Cover for Directors and Officers Liability?
Yes
No
Do You Want Optional Cover For Non-IT Contingent Business Interruption And System Failure?
Yes
No
Do You Want Optional Cover For Tangible Property?
Yes
No
Excess
- Select -
$2,500
$5,000
$7,500
$10,000
Business Interruption Indemnity Period
- Select -
30 days
60 days
90 days
180 days
365 days
Aggregate Limit
- Select -
$250,000
$500,000
$750,000
$1,000,000
More
Have you had any previous claims declined?
- Select -
Yes
No
Ever been charged or convicted of a criminal offence?
- Select -
Yes
No
Ever had an insurance policy cancelled, declined or terms imposed?
- Select -
Yes
No
Aware of circumstances which could give rise to a claim?
- Select -
Yes
No
Anything to Declare under Duty of Disclosure?
- Select -
Yes
No
Additional Information about you or the property
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