Personal Information 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
General Information Current Number of Employees
Details of your Main Business Operations
Annual Gross Revenue / Turnover *
Last Year
Current Year
Next Year (Estimated)
Personal Data Collection Identify the Type of PII¹ Data Retained on Your Network
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
Network Information 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
Historical Information During the last three years have you:
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:
Final Signature
Data Protection
By accepting this insurance you consent to Ascent Underwriting 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 proposal 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 proposal 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 managers, or employees to enable you to answer the questions accurately.
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
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Additional Notes
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