CYBER Insurance

 

Complete 0%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

Details of Proposed Insured

Insured/Practice Name *
Contact Person *
Address
Suburb
City
Province/State/Region
Physical Code
Tel No 011 000 1234
Email *
Company Registration No
Cell No *011 000 1234
Website
VAT No Numbers only
Present Legal Constitution*
Sole Practitioner
Partnership
Incorporated Co
Limited Co
Closed Corp
Other

Date of commencement of Practice:

As currently constituted
As initially established
Number of Employees
If yes, please provide full details:

Names and Qualifications of Employees (attach CV, ID's and Company Profile/Brochure copies below)

Name
Date Qualified
Qualifications
Name
Date Qualified
Qualifications
Name
Date Qualified
Qualifications
Upload ID Copies Max Size 10MB. 10 Files Max
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Complete 9%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

1. Nature of Operations

1.1. Please provide a detailed description of the Nature of Operations.

2. Details Of Products and Services Offered

2.1. Please provide details of the products and services offered. If engaged in multiple disciplines, please provide a percentage split - total must add up to 100%.

3. Mergers & Acquisitions

3.1. Have you been involved in any mergers and acquisitions within the last three years?
Yes
No
None
3.1.1. If Yes, please detail these subsidiaries area below.

4. Insurance History

4.1. Are you in the present or have you in the past been Insured for this type of Insurance now being proposed?
Yes
No
None

If yes, please provide the following details:

4.1.1. Name of Insurers
4.1.2. Date cover expires(d)
4.1.3. Retroactive date
4.1.4. Limit of Liability Numbers only
4.1.5. Current premium Numbers only

4.2. For the type of Insurance now being proposed, has any Insurer ever:

4.2.1. declined a Proposal or renewal for this Practice or any Partner/Principal?
Yes
No
None
4.2.2. required an increased premium or imposed special terms?
Yes
No
None
4.2.3. cancelled an insurance?
Yes
No
None
4.2.4. If yes, please provide full details:

5. Required Cover

5.1. State the Limit of Indemnity and excess required.

5.1.1. Limit (R) Numbers Only
5.2.1. Excess (R) Numbers Only
5.1.2. Limit (R) Numbers Only
5.2.2. Excess (R) Numbers Only
5.1.3. Limit (R) Numbers Only
5.2.3. Excess (R) Numbers Only
5.2. Do you require cover in respect of liability incurred but not discovered prior to the effecting of this insurance at a single premium to be negotiated?
Yes
No
None
5.3. Please mark which sections of the Cyber Risk offering you wish to incorporate within your policy.
Professional Services/Errors and Omissions
Network Security and Privacy Liability
Privacy Regulatory Defence and Penalties
Date Extortion
Multimedia Liability
Data Rectification and Business Interruption
Crisis Management Costs
None
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Complete 18%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

6. Previous Losses/Existing Circumstances

6.1. Is any Principal, AFTER FULL ENQUIRY, aware of any circumstance which might:

6.1.1. Give rise to a claim against the Proposer, any predecessor, or any past or present Principal?
Yes
No
None
6.1.2. Cause any loss to the Proposer, any predecessor or any past or present Principal?
Yes
No
None
6.1.3. Otherwise affect the consideration or this proposal for insurance?
Yes
No
None
6.1.3.A. If Yes, please identify details (including loss date, amount claimed and brief description):
6.2. In respect of any of the risks to which this proposal relates, has any Claim been made (whether successful or not) against the Proposer or any past or present Principal?
Yes
No
None
6.2.1. If Yes, please identify details (including loss date, amount claimed and brief description):
6.3. What steps have been taken to prevent a recurrence?
6.4. Have you or any past or present principal, partner, director or employee ever been disciplined for mishandling data or otherwise tampering with your computer network?
Yes
No
None
6.5. Have you or any past or present principal, partner, director or employee been subject to any disciplinary action or governmental action or investigation as a result of professional activities?
Yes
No
None
6.6. Have you sustained any unscheduled network outage or interruption within the past 24 month?
Yes
No
None
6.7. Have you ever suffered an international breach of IT security, network damage, system corruption or loss of data?
Yes
No
None
6.8. Have you ever sustained a material or significant system intrusion, tampering, virus malicious code attack, loss of data, hacking incident, data theft or similar incident or situation?
Yes
No
None
6.9. During the last three years, have you notified customers or other person, or entity alleged that their personal information was compromised?
Yes
No
None
6.10. During the last three years have you notified customers that their information was or may have been compromised?
Yes
No
None
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Complete 27%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

7. Financial Information

7.1. What is the date of the Company’s financial year-end?

7.2. Please give the audited fees for the past 5 years:

2019 Fees (Rand) Numbers in Rands
2020 Fees (Rand) Numbers in Rands
2021 Fees (Rand) Numbers in Rands
2022 Fees (Rand) Numbers in Rands
2023 Fees (Rand) Numbers in Rands
Estimate for the next 12 months (Rand) Numbers in Rands
7.3. Percentage of gross annual revenue accounted for by sales or operations through your website (%) Numbers Only
7.4. Percentage of annual transactions paid for by debit/credit card (%) Numbers Only
7.5. Average transaction value (%) Numbers Only

7.6. Percentage of last year’s gross annual revenue generated from:

7.6.1. SA client subject to SA laws (%) Numbers Only
7.6.2. Clients subject to US laws (%) Numbers Only
7.6.3. Clients anywhere else in the world (%) Numbers Only
7.7. Estimate of total annual IT system budget (%) Numbers Only

8. Errors and Omissions Coverage

8. Do you require Errors & Omissions Coverage?
Yes
No
None
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Complete 36%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

8. Errors and Omissions Coverage Details

8.1. Percentage of gross annual revenue by services performed in last financial year.

8.1.1. Hardware - Sales (%) Numbers in Rands
8.1.2. Hardware - Installation (%) Numbers in Rands
8.1.3. Software - Off the shelf product sales (%) Numbers Only
8.1.4. Software - Installation and configuration (%) Numbers Only
8.1.5. Software - Development of custom or bespoke software products (%) Numbers Only
8.1.6. Software - Maintenance (%) Numbers Only
8.1.7. Services - Consultancy (%) Numbers Only
8.1.8. Services - Supply of staff (%) Numbers Only
8.1.9. Services - Facilities management (%) Numbers Only
8.1.10. Services - Training services (%) Numbers Only
8.1.11. Services - Web design (%) Numbers Only
8.1.12. eCommerce - Internet sales revenue (%) Numbers Only
8.1.13. eCommerce - Internet marketing revenue (%) Numbers Only
8.1.14. Other Work (%) Numbers Only
8.1.14.A. Please provide details of other work.

Total must add up to 100%

8.2. Details of your three largest contracts which have been undertaken in the last three years:

8.2.1. Client/Business 1
8.2.1. Total Contract Value Numbers Only
8.2.1. Contract Length
8.2.1. Services Provided
8.2.2. Client/Business 2
8.2.2. Total Contract Value Numbers Only
8.2.2. Contract Length
8.2.2. Services Provided
8.2.3. Client/Business 3
8.2.3. Total Contract Value Numbers Only
8.2.3. Contract Length
8.2.3. Services Provided
8.3. Do you typically undertake contracts which are longer than 2 years in duration?
Yes
No
None
8.4. Do you use outside consultants/contracts, or subcontract work to others?
Yes
No
None
8.4.1. If Yes, approximate percentage of last year’s gross annual revenue which this represents (%) Numbers Only
8.5. Do you normally require consultants/contractors to hold professional Indemnity cover?
Yes
No
None
8.6. Do you enter into written contracts with all clients?
Yes
No
None

8.7. Do your written contracts with clients contain the following clauses/provisions:

8.7.1. Limitations of liability, including limiting consequential damages.
Yes
No
None
8.7.2. Disclaimer of warranties.
Yes
No
None
8.7.3. Arbitration clause.
Yes
No
None
8.8. Value of average client contract (R) Numbers Only
8.9. Value of largest single client contract (R) Numbers Only
8.10. Do you ensure that changes to the original contract are agreed by both parties and documented in writing, which is then incorporated into the main contract?
Yes
No
None
8.11. Are all contracts reviewed by legal counsel prior to commencing any work?
Yes
No
None
8.12. Are variations to contracts reviewed by legal counsel?
Yes
No
None
8.7.9. Do you have quality control procedures in force to test all software and products prior to release?
Yes
No
None

8.13. Is the failure of your products or any of your services likely to result in any of the following outcomes?

8.13.1. Damage or destruction to physical property?
Yes
No
None
8.13.2. Death or bodily injury?
Yes
No
None
8.13.3. Immediate and significant financial loss?
Yes
No
None
8.13.4. Insignificant financial loss?
Yes
No
None
8.14. Have there been any significant changes in the nature or size of your business in the past 12 months?
Yes
No
None
8.14.1. If Yes, please provide full details or upload a separate sheet(s) at the bottom of this section.
8.15. Do you anticipate any change in the nature or size of your business over the next 12 months?
Yes
No
None
8.15.1. If Yes, please provide full details or upload a separate sheet(s) at the bottom of this section.
8.16. Do you plan on releasing or introducing new products, software and/or services within the 12 months?
Yes
No
None
8.16.1. If Yes, please provide full details or upload a separate sheet(s) at the bottom of this section.
8.17. Have you released or introduced new products, software and/or services within the past 12 months?
Yes
No
None
8.17.1. If Yes, please provide full details or upload a separate sheet(s) at the bottom of this section.
8.18. Have you ever had to recall any of your electronic products or software for any reason?
Yes
No
None
8.18.1. If Yes, please provide full details or upload a separate sheet(s) at the bottom of this section.
8.19. Over the past three years, have any customers refused to pay or request a refund or invoked contract penalty clauses outside the normal course of business?
Yes
No
None
8.19.1. If Yes, please provide full details or upload a separate sheet(s) at the bottom of this section.
8.20. Do you have a formal process in place for resolving disputes with clients?
Yes
No
None
8.21. Have you ever instituted adversarial proceedings in order to recover unpaid fees from a client?
Yes
No
None
8.22. Upload any documents as required
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Complete 45%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

9. Network Dependency

9.1. Number of days each year your computer network is active. Numbers Only
9.2. Usual daily hours of operation?
9.3. Do you outsource the management or any part of your IT operations?
Yes
No
None
9.3.1. If Yes, please provide brief details below (or upload a separate sheet(s) at the bottom of this section), including what is outsourced and to whom?
9.4. Provide details of your internal IT network functions.
9.5. Indicate time after which the inability to staff to access your internal computer network and systems would have a significant impact on your business?
Immediately
After 6 Hours
After 12 hours
After 48 hours
Never
None
9.6. Is the operation and connectivity of your computer network business critical?
Yes
No
None
9.7. Indicate time after which the inability to customers to access your website would have a significant impact on your business?
Immediately
After 6 Hours
After 12 hours
After 48 hours
Never
None
9.8.. Please provide brief details below (or upload a separate sheet(s) at the bottom of this section), of the impact on our business if your internal network or application should fail or be disrupted (include commercial relations, revenue and image).
9.9. Upload any documents as required
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Complete 54%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

10. Business Continuity

10.1. Please provide brief details below (or upload a separate sheet(s) at the bottom of this section), your recovery/contingency plans to avoid business interruption due to IT system failure, and/or alternative working procedures (interdependency, outsourcing, alterations of process, additional employment, redundant servers etc).
10.2. Is this plan regularly tested and updated?
Yes
No
None
10.3. Have you recently carried out an IT security audit?
Yes
No
None
10.3.1. Audited By
10.3.2. Date Audited
10.4. When was your last external penetration test carried out?
10.5. Was your serious concern raised with any aspect of the network where immediate correction was advised?
Yes
No
None
10.5.1. If Yes, were the recommendations carried out?
Yes
No
None
10.6. Upload any documents as required
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Complete 63%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

11. Network Security

11.1. Do you employ a Chief Privacy Officer or Chief Information Officer, who has a responsibility for meeting your worldwide obligation under privacy and data protection laws?
Yes
No
None
11.2. Does your security and privacy policy include mandatory training for all employees?
Yes
No
None
11.3. Are all employment positions analysed and employees assigned specified rights, privileges and unique user ID and passwords, which are changed periodically?
Yes
No
None
11.4. Do you have strict user revocation procedures on user accounts and inventoried recovery of all information assets following employment termination?
Yes
No
None
11.5. Do you conduct regular reviews of your third-party service providers and partners to ensure that they meet your requirements for protecting sensitive information on their care?
Yes
No
None
11.6. Do you enforce provisions for non-compliance by employees, contractors & others?
Yes
No
None
11.7. Do you have antivirus software on all computer devices, servers and networks which are updated in accordance with the software providers’ recommendations?
Yes
No
None
11.8. Do you have firewalls and intrusion monitoring detection in force to prevent and monitor unauthorised access?
Yes
No
None
11.9. Do you have access control procedures and hard drive encryption to prevent unauthorised exposure of data on all laptops, PDA’s, smartphones, and home-based PCs?
Yes
No
None
11.10. Have you configured your network to ensure that access to sensitive data is limited to properly authorised requests?
Yes
No
None
11.11. Do you ensure that all wireless networks have protected access?
Yes
No (Please upload)
None
11.12. Do you encrypt all sensitive information that is physically removed from premises by tape, disk hard drive or other means?
Yes
No (Please upload)
None
11.13. Is all sensitive and confidential information that is transmitted within and from your organisation encrypted using industry grade mechanisms?
Yes
No (Please upload)
None
11.14. Is all sensitive and confidential information stored on your database, servers and data files encrypted? 
Yes
No (Please upload)
None
11.15. If you answered no to the above 4 questions, please provide details on a separate sheet, briefly describing the nature of the unprotected information and what security measures are in place to protect this information in the absence of encryption.
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Complete 72%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

12. Information and Data Management

12.1. Does your information asset programme include a data classification (e.g. public, internal use only, confidential)?
Yes
No
None
12.2. Do you post a privacy policy on your website which has been reviewed by a qualified lawyer?
Yes
No
None
12.3. Do you have an information asset inventory that lists the owners and sources of all data?
Yes
No
None
12.4. Do you have procedures in force for honouring the specific marketing ‘opt-out’ requests of your customers that are consistent with the terms of your published privacy policy?
Yes
No
None
12.5. Do you have procedure in force for monitoring the period for which customer data is held, and have procedures for deleting this information at the end of that period?
Yes
No
None
12.6. Do you have procedures in force for deleting all sensitive data from systems and devices prior to their disposal from the company?
Yes
No
None
12.7. Is all information held in physical form (paper, disks, CDs etc) disposed of or recycled by confidential and secure methods which are recognised throughout the organisation?
Yes
No
None
12.8. Do you keep an incident log of all system security breached and network failures?
Yes
No
None
12.9. Are you complaint with the Payment Card Industry (PCI) Data Security Standards?
Yes
No
None
12.9.1. If Yes, to what level?
1
2
3
4
None
12.10. How many individual personally identifiable records (IPIR) are retained within your network and database? Numbers Only

IPIR are any records which can be identifies and connected to a specific individual. For example, a company which holds the cellphone number, bank account number, residential address and ID number of a person will hold hour unique records (IPIR). Please provide an estimate of the total number of IPIR held within your network at any given time.

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Complete 81%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

13. General Questions

13. Have you or any of the applicant’s principals, partners, directors, risk managers or employees:

13.1. Ever been convicted of or is any prosecution pending for any offence involving dishonesty of any kind (including but not limited to offense involving fire, fraud, theft or handling stolen goods)?
Yes
No
None
13.1.1. If Yes, please provide full details.
13.2. Been declared bankrupt, the subject of bankruptcy proceedings or of any voluntary or mandatory insolvency or winding up procedures?
Yes
No
None
13.1.2. If Yes, please provide full details.
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Complete 90%
1 Details 2 Sections 1 - 5 3 Section 6 - Previous Losses/Existing Circumstances 4 Section 7 - Financial Information 5 Section 8 - Errors & Omissions Coverage 6 Section 9 - Network Dependency 7 Section 10 - Business Continuity 8 Section 11 - Network Security 9 Section 12 - Information & Data Management 10 Section 13 - General 11 Declaration

I/We the undersigned duly authorised person(s) declare that:

  1. I am/we are authorised by each of the Insureds to sign this Proposal Form.
  2. The above statements are correct, true and complete.
  3. No information material to this Proposal Form has been withheld.
  4. I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure.
  5. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure.
  6. Apart from what is disclosed in this document, I/we are not aware of any request for records being made by a patient, family member of a patient, or an attorney nor have I/we received a letter from an attorney regarding treatment which was provided to a patient.
  7. Apart from what is disclosed in this document, I/we are not aware of any circumstance which might reasonably lead to a claim or suit being lodged against me, regardless of whether I/we view that suit to be without merit.
  8. I/we understand that no insurance is in force until such time as the Insurer has confirmed acceptance of the proposed insurance.
  9. I/we undertake to inform the Insurer of any material alteration to these facts occurring before completion of the contract of insurance.
  10. I/we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance.
  11. I/we acknowledge that the signing of this proposal form binds neither myself to accept the subsequent quote, nor does it bind the Insurer to accept the proposal. It is agreed that all written statements and attachments furnished to the Insurer in conjunction with this proposal are hereby incorporated by reference into this proposal and made part thereof.
  12. Except where indicated to the contrary, I/we understand that any statement made in this Proposal Form will be treated by the Insurer as a statement made by all persons to be insured.
I Agree*
Yes
First Name *
Surname *
Date *
Submit
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