Business Name

First Name

Last Name

If Yes click the box for confirmation *

The Applicant’s network, systems and applications are protected by firewall(s) and anti-malware

The Applicant’s network, systems and applications are patched within 30 days of the release of any critical security updates

The Applicant only uses systems and applications that are currently supported by the vendor

The Applicant’s network, systems and applications are backed up on at least a weekly basis with backups stored off-line

The Applicant verifies all recipient bank account information before making any wire transfer payments

Are the following statements true? Click box if yes

You have not aware of any facts, acts, circumstances, or situations that may give rise to a claim, privacy regulation proceedings or fines or PCI fines or assessment against the Applicant under the insurance policy for which the Applicant is applying

In the past 3 years you have not experienced any privacy breaches which resulted in the unauthorized disclosure, theft or loss of third party personally identifiable information or proprietary business information

In the past 3 years you have not experienced any cyber attacks to its network, systems or applications which resulted in business income loss, recovery expenses or a ransom payment?

In the past 3 years you have not received notice of any actual or potential infringement of a third party’s intellectual property rights, including, but not limited to, patent, copyright, trademark, or domain name

In the past 3 years you have not experienced any business email compromise or social engineering attacks which resulted in the loss or theft of wire transfer funds