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1 GENERAL INFORMATION
2 TECHNOLOGY SERVICES ERRORS & OMISSIONS
3 MISCELLANEOUS PROFESSIONAL SERVICES ERRORS & OMISSIONS
4 SECURITY AND PRIVACY
5 MULTIMEDIA
6 CLAIMS AND EXPIRING INFORMATION
7 SIGN & SUBMIT
CYBER RISK INSURANCE APPLICATION
GENERAL INFORMATION

As used throughout this application, “you” means the person signing the application, as well as the entity seeking insurance and the applicant’s principals, partners, directors, risk managers, or employees that are in a supervisory role. The questions contained in this application pertain to all persons or entities seeking
insurance, and not just the signatory.

Please answer all the questions on this form. Before any question is answered, please carefully read the declaration at the end of the application form, which you are required to sign. In this context, ANY INSURANCE COVERAGE THAT MAY BE ISSUED UPON THIS FORM WILL BE VOID IF THE FORM CONTAINS FALSEHOODS, MISREPRESENTATIONS OR OMISSIONS. PLEASE TAKE CARE IN FILLING OUT THIS FORM.

TECHNOLOGY SERVICES ERRORS & OMISSIONS
Do your services include any of the following?
Do you provide services/products to the following industries?
Please confirm that less than 10% of your end users are consumers as opposed to commercial customers?
Where you develop software, please confirm that this has been reviewed by legal counsel prior to release?
MISCELLANEOUS PROFESSIONAL SERVICES ERRORS & OMISSIONS
Do you provide any of the following services; legal, financial, architectural, real estate or medical?
Please confirm that you enter into written contracts with your clients at all times?
SECURITY AND PRIVACY
If you store sensitive information or PII on laptops and portable media devices, please confirm that the data is encrypted?
Do you have access control procedures and hard drive encryption to prevent unauthorised access on your databases, servers and data files?
Do you have a business continuity plan and data backup or recovery procedures in force to avoid business interruption due to system failure for all mission critical systems?
Please confirm up-to-date compliance with privacy provisions of relevant regulatory and industry frameworks (in particular Gramm-Leach Bliley Act, Health Insurance Portability & Accountability Act, Payment Card Industry (PCI) Data Security Standard, General Data Protection Regulation (GDPR))?
MULTIMEDIA
Do you have procedures in place to review media content prior to release on your website and take down procedures in respect of any user generated content?
CLAIMS AND EXPIRING INFORMATION
During the last three years have you:

a) Sustained any unscheduled network outages, intrusion, corruption or loss of data?
b) Received notice or become aware of any privacy violations or been subject to any disciplinary, regulatory
actions, sanctions or penalties?
c) Been involved in a lawsuit, claim or settled any allegations of a suit?
d) Become aware of any circumstance or incident that could be reasonably anticipated to give rise to a claim
against the type of insurance being requested in this application?

Do you currently have insurance in place for the type of coverage being requested above?

Data Protection

By accepting this insurance you consent to EMET INTERNATIONAL INSURANCE using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example health information or criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities.

Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and in compliance with relevant Data Protection legislation. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.


IMPORTANT – CyberPro Policy Statement of Fact

By accepting this insurance you confirm that the facts contained in the application form are true. These statements, and all information you or anyone on your behalf provided before we agree to insure you, are incorporated into and form the basis of your policy. If anything in these statements is not correct, we will be entitled to treat this insurance as if it had never existed. You should keep this Statement of
Fact and a copy of the completed application form for your records. 

This application must be signed by the applicant. Signing this form does not bind the company to complete the insurance. With reference 
to risks being applied for in the United States, please note that in certain States, any person who knowingly and with intent to defraud any insurance company or other person submits an application for insurance containing any false information, or conceals the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.


The undersigned is an authorized principal, partner, director, risk manager, or employee of the applicant and certifies that reasonable 
inquiry has been made to obtain the answers herein which are true, correct and complete to the best of his/her knowledge and belief. Such reasonable inquiry includes all necessary inquiries to fellow principals, partners, directors, risk manager, or employees to enable you to answer the questions accurately.

By checking this box and typing my name below, I am electronically signing my application.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

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