Your Full Name
Email Address
Phone
Website
Street Address
City
Province or Territory ------- Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Ontario Prince Edward Island Québec Saskatchewan Northwest Territories Nunavut Yukon
Postal Code
Current Number of Employees
Details of your Main Business Operations
Last Year
Current Year
Next Year (Estimated)
Is Payment Card Information Collected? -- Please Choose -- Yes No
Is Health Care Data Collected? -- Please Choose -- Yes No
Is Any Other Data Collected? -- Please Choose -- Yes No
If you have answered ‘Yes’ to any of the options directly above, please provide details of the nature of this PII.
Please provide the nature of other data collected
Do you have a business continuity plan in force to avoid business interruption due to systems failure? -- Please Choose -- Yes No
Are all portable and mobile devices encrypted? -- Please Choose -- Yes No
Please detail the type and how much PII is stored on portable media devices and how it is protected in the absence of encryption.
Do you have firewalls and automatically updating antivirus software in force across your network? -- Please Choose -- Yes No
Is all sensitive and confidential information stored on your databases, servers and data files encrypted? -- Please Choose -- Yes No
Is all information held in a physical form disposed of or recycled by confidential and secure methods? -- Please Choose -- Yes No
Do you have a privacy policy on your website which has been legally reviewed and includes a statement advising users as to how any information collected will be used and for what purposes? -- Please Choose -- Yes No
Do you have a process in force to obtain a legal review of all media content and advertising materials prior to release? -- Please Choose -- Yes No
Please confirm up-to-date compliance with relevant regulatory and industry framework (e.g. Gramm-Leach Bliley Act, Health Insurance, Portability & Accountability Act (HIPAA), Payment Card Industry (PCI), Data Security Standard, CAN-SPAM Act, TCPA or similar). -- Please Choose -- Confirmed Unconfirmed
Sustained any unscheduled or unintentional network outage, intrusion, corruption or loss of data? -- Please Choose -- Yes No
Received notice or become aware of any privacy violations or that any data or personally identifiable information has become compromised? -- Please Choose -- Yes No
Received any injunction(s), lawsuit(s), fine(s), penalty(s) or sanction(s)? -- Please Choose -- Yes No
Been subject to any disciplinary action, regulatory action, or investigation by any governmental, regulatory or administrative agency? -- Please Choose -- Yes No
Become aware of any circumstance or incident that could be reasonably anticipated to give rise to a claim against the type of insurance(s) being requested in this application? -- Please Choose -- Yes No
If you've answered ‘yes’ to any questions within this section (historical information), please provide full details:
Signature (Type Full Name)
Position
Date of Birth DD/MM/YY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
January February March April May June July August September October November December
1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Additional Notes
Submit My Message
String domain city type
