CYBER INSURANCE APPLICATION FORM

Please fill out the cyber insurance application below to the best of your ability.  If you have any issues, please don’t hesitate to call us at 1-250-365-3368.  We will follow up after we successfully receive your submission.

    CYBER APPLICATION (Please complete ALL questions)

    Owner(s) Full Legal Name:

    Date of Birth:

    Address / Postal Code:

    Occupation:

    Email:

    Phone:

    How did you hear about us:

    Technical Assessment:

    Do you have anti-virus software installed on your computer system? YesNo

    Have the passwords on your computer system and connected home devices been changed from the default password that existed on the computer system or home devices?YesNo

    Claims:

    Have you had any claims or circumstances of cyber-attacks, cyber extortion threats, identity theft, credit card fraud, phishing, or other liability or property claims or financial losses within the past 5 years?YesNo

    If yes, how many have you had?

    Please describe the incident(s)

    Are you aware of any cyber-attacks, cyber extortion threats, identity theft, credit card fraud, phishing attempts in the last 30 days? YesNo

    Aggregate Limit Required

    $25,000$50,000$100,000$250,000$500,000

    Cyber Bullying extension? YesNo

    Cyber Bullying Expenses

    - reasonable expenses that insured or family member incur the cost of up to 20 hours of psychiatric services, professional digital forensic analysis, professional cyber security consultant service, professional public relations consultant

    Cyber Bullying Events

    - means a series of three or more similar or related acts by the same person or group of persons that are
    intended to intimidate, harass, humiliate or defame that are committed against insured or family member