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Request a Cyber Insurance Quote

Cyber Insurance Application

Cyber Insurance Application

Thank you for your interest!
Completion of this application should take 15-20 minutes.
Minimum premiums for cyber coverage through this program begin at $1,500.
Someone from our office will contact you by the end of the next business day to discuss coverages and limits.

We offer coverage in your state.

General Information
General Underwriting Questions
Employment Practices
Past Experience
Questions for Insuring Agreement 1 Coverage Only
Questions for Insuring Agreement 2 through 8 Coverages
NOTICE TO APPLICANT – PLEASE READ CAREFULLY
For the purpose of this Application, the undersigned authorized officer of the organization named in General Information of this Application declares that to the best of the organization’s knowledge the statements herein are true, accurate and complete. The insurer is authorized to make any inquiry in connection with this Application. Signing this Application does not bind the insurer to issue, or the applicant to purchase, any insurance policy issued in connection with this Application. If the information in this Application materially changes prior to the effective date of the policy, the applicant will promptly notify the insurer, who may modify or withdraw the quotation.
The undersigned declares that the individuals and entities proposed for this insurance have been notified that:
• This policy applies only to “claims” first made or deemed made against an “insured” during the “policy period” or during the applicable extended reporting period; and
• The limit of liability is reduced by amounts incurred as “defense expenses” and such expenses will be subject to the deductible amount.
Words within quotation marks are defined in the insurance policy.
Misrepresentation of any material fact in this Application may be grounds for rescission of this policy.
FRAUD STATEMENT
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Thank you for your interest. Unfortunately we are unable to offer Cyber Insurance Quotes in your state at this time.

Please Select Your State to Begin

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