Cyber INSURANCE Application Schedule a Free Consultation Questions for Coalition Cyber Insurance and (Optional) Technology Errors & Omissions Insurance Responses to the questions below are necessary to obtain a quotation for Cyber insurance from Coalition and, if desired, Technology Errors & Omissions coverage. Attestation Questions must be completed for both standalone Cyber insurance and Technology Errors & Omissions coverages. After a quotation for insurance is bound, the Named Insured will be asked to electronically sign an application populated with the responses from the questions below. The information you provide is safeguarded using advanced encryption methods and secure server protocols, ensuring that your data remains private and protected against unauthorized access. We prioritize your security and confidentiality with industry-leading measures.NAMED INSUREDWEBSITE DOMAIN(S)PRIMARY INSURED EMAIL CONTACT SECURITY/IT EMAIL CONTACT Address STREET ADDRESS CITY STATE ZIP INDUSTRYNO. OF EMPLOYEESREVENUE(Required)GROSS PROFIT / NET REVENUE(Required)Next 12 monthsAttestation Questions1. Within the last 3 years has Named Insured suffered any cyber incidents resulting in a claim in excess of $25,000? (If Yes) please explain the cyber incidents and/or claims. Yes No Please explain the cyber incidents and/or claims.2. Is Named Insured aware of any circumstances that could give rise to a claim under this insurance policy? (If Yes) please explain the circumstances and/or potential claims. Yes No Explain the circumstances and/or potential claims.3. Does Named Insured implement encryption on laptop computers, desktop computers, and other portable media devices? Yes No Sometimes 4. Does Named Insured collect, process, store, transmit, or have access to any Payment Card Information (PCI), Personally Identifiable Information (PII), or Protected Health Information (PHI) other than employees of Named Insured? Yes No 4a (If Yes) What is the estimated annual volume of payment card transactions (credit cards, debit cards, etc.)? No Records Less than 100,000 100,000 - 500,000 500,000 - 1,000,000 Over 1,000,000 4b (If Yes) How many PII or PHI records does Named Insured collect, process, store, transmit, or have access to? No Records Less than 100,000 100,000 - 500,000 500,000 - 1,000,000 Over 1,000,000 5. For which of the following services do you enforce Multi-Factor Authentication (MFA)?5a Email Yes No 5b Virtual Private Network (VPN), Remote Desktop Protocol (RDP), RDWeb, RD Gateway, or other remote access Yes No N/A 5c Network/cloud administration or other privileged user accounts Yes No 6. Does Named Insured maintain at least weekly backups of all sensitive or otherwise critical data and all critical business systems offline or on a separate network? Yes No N/A 7. Does Named Insured require a secondary means of communication to validate the authenticity of funds transfers (ACH, wire, etc.) requests before processing a request in excess of $25,000? Yes No N/A 8. Within the last 3 years has Named Insured been subject to any complaints concerning the content of its website, advertising materials, social media, or other publications? Yes No N/A 9. Does Named Insured enforce procedures to remove content (including third party content) that may infringe or violate any intellectual property or privacy right? Yes No N/A Technology Errors & Omissions Questions Questions below are required only for Technology Errors & Omissions coverage.1. Please describe the company's use of technology in delivering its product and/or services.2. Within the last 3 years has Named Insured been subject to a dispute or claim arising out of a technology error or omission in excess of $25,000? Yes No N/A 3. Is Named Insured operating as a managed service provider (MSP), or does Named Insured participate directly in or sell technology NO products/services designed for any of the following industries? Yes No Cryptocurrency Cannabis Internet of Things Financial Services Financial Services Blockchain Automotive Aviation Military/Defense Gambling Payment Processing Adult Entertainment Payment Processing Point of sale (POS) Software/ Hardware / Reseller Professional Services (Legal, Medical, A&E, or other licensed professional services) 4. How often are Named Insured's services provided by written agreement or contract? 100% OF AGREEMENTS OR CONTRACTS ≥50% OF AGREEMENTS OR CONTRACTS <50% OF AGREEMENTS OR CONTRACTS 0% OF AGREEMENTS OR CONTRACTS 5. Identify the standard risk mitigating clauses or methods contained within Named Insured's agreements or contracts. (Select all that apply) CUSTOMER ACCEPTANCE / FINAL SIGN OFF DISCLAIMER OF WARRANTIES HOLD HARMLESS AGREEMENTS THAT BENEFIT NAMED INSURED LIMITATION OF LIABILITY EXCLUSION OF CONSEQUENTIAL DAMAGES INDEMNIFICATION CLAUSE BINDING MANDATORY ARBITRATION PROJECT PHASES/MILESTONES Δ
