Cyber Liability Online Form Cyber Liability Applicant's Name Business Name Phone# E-mail Address Address Address Description of Primary Operations # Employees Payroll Provide Dollar Amount Gross Sales Provide Dollar Amount Describe all professional services performed for others and indicate the percentage of gross revenues derived from each activity Include Percentage Services ctd. * Include Percentage Services ctd. * Include Percentage Have You ever been subject to any complaints, including cease and desist orders concerning the content of Your website, advertising materials, social media or other publications or broadcasts? Yes No Do you utilize the services of independent contractors or subcontractors to perform your business activities? Yes No Do you always utilize a written contract with independent contractors/ subcontractors? Yes No Do you require independent contractors/subcontractors to carry their own professional liability insurance? Yes No What percentage of your business activities are contracted out? Yes No Has any customer or client alleged financial loss resulting from Your business activities over the last five years? Yes No Are alternative facilities available in the event of a shutdown/failure of the Applicant’s network? Yes No Does the Applicant have written procedures for routine backups and maintain proof of backups? Yes No Please provide the amount of confidential information (in both electronic and non-electronic form) you process or store on an annual basis. If you do not know exact amounts, please provide estimates; Social security number or individual taxpayer identification numbers # of Social security number or individual taxpayer identification numbers Financial account record (e.g. bank accounts): # of Financial account record (e.g. bank accounts) Payment card data (e.g. credit or debit card): # of Payment card data (e.g. credit or debit card) Drivers license number, passport number or other state or federal identification number: # of Drivers license number, passport number or other state or federal identification number Protected health information (PHI): # Protected health information (PHI) Other personal identifiable information and confidential information: # of kept records Is the Applicant or any principal, partner, owner, officer, director, employee, manager or managing member of the Applicant or any person(s) or organization(s) proposed for this insurance aware of any fact, circumstance, situation, incident or allegation of negligence or wrongdoing, which might afford grounds for any claim such as would fall under the proposed insurance? Yes No During the last five years, have there been any claims or proceedings arising out of professional services against the Applicant, or any of its principals, partners, owners, officers, directors, employees, managers, managing members, its predecessors, subsidiaries, affiliates, and/or against any other person or organization proposed for this insurance? Yes No Current Dec Page/Loss Run Report Submit If you are human, leave this field blank.