Cyber Liability Insurance

Please enable JavaScript in your browser to complete this form.
Auto Quote Sheet Header

515 E. Carefree Hwy.
PMB 857
Phoenix, AZ 85085
623-465-5300
Email: insurance@pibinc.com
8:00AM - 5:00PM MST
Monday to Friday

Cyber Liability Insurance

Application Form:

5) Total Revenues:

  a) Does the site have a Privacy Statement?

Privacy Statement
  b) Is there any publicly accessible environment for posting/sharing information?
Posting/Sharing information

If Yes to 6) b) then are there established procedures for editing/removing libelous content that infringes the Intellectual Property Rights (copyright, trademark etc.) of others?

If Yes to 6) b)

7) Does Applicant have:

  a) An email and internet usage policy that has been shared with all staff?
Email and Internet usage policy
  b) Firewall System in place?
Firewall System in place
  c) Mandatory individual nontrivial ID and passwords with periodic password changes?
Mandatory individual nontrivial ID

  d) All PCs and servers protected with up-to-date anti-virus software?

All PCs and servers protected
8) Are 3rd party vendor(s) used to outsource data storage or other IT functions?
Are 3rd party vendor(s) used

9) Please indicate the total number of records (PII / PHI) stored on your network:

Total number of records

10) Compliance

  a) Gramm-Leach Bliley Act of 1999
Gramm-Leach Bliley Act of 1999
  b) Payment Card Industry (PCI) Data Security Standards
(PCI) Data Security Standards
  c) HIPAA Act of 1996 (Healthcare)
HIPAA Act of 1996 (Healthcare)
If yes to any/all, please confirm last audit was within past year?
If yes to any/all
11) Is there a Business Recovery/Continuity Plan in place for IT systems failure?
Is there a Business Recovery
12) Does applicant have ANY business with individuals or organizations in sanctioned countries including but not limited to Iran, Syria, North Korea, North Sudan and Cuba being subject to certain US, EU, UN and/or other national sanctions restrictions?
Does applicant have ANY business with
13) When transferring funds into bank accounts, where a transfer has not previously been made, is verbal communication with the recipient (via a verified telephone number) used to approve the request?
When transferring funds
14) In the past 5 years has the Applicant:
  • a) Sustained a significant system intrusion, tampering, virus or malicious code attack, loss of data hacking incident, data theft or similar incident?
Sustained a significant system
  • b) Had anyone allege their personal information was compromised, or have you notified customers that their information was or may have been compromised?
Had anyone allege their
c) Sustained any unscheduled network outage or interruption in the past 24 months?
Sustained any unscheduled network outage
  • d) Experienced any claims or are you aware of any circumstances that could give rise to a claim that may have been covered by this policy?
Experienced any claims
If Yes to any of Q14 above then please provide details (continue on separate sheet if required) and include: Details of what happened, any remedial action undertaken to prevent repetition & any costs to insured or its insurers.
15) Does the applicant have multi-factor authentication (MFA/2FA) enabled on email access and remote network access?
Does the applicant have multi-factor
Declaration: I hereby declare that I am authorized to complete this Application on behalf of the Applicant(s) and that after due inquiry, to the best of my knowledge and belief, the statements and particulars in this Application are true and complete and no material facts have been misstated, suppressed, or omitted.
Clear Signature
Sign with your mouse or touch screen. To clear, click the "X" in the top right corner.