1: Application Name:
2: Contact Name:
Address:
Phone:
Website:
Email:
3: Business Activity: (Please describe)
4: Total Revenue of the company of the company for the past 12 month:
5: Coverage Required: (please indicate the level of coverage required by ticking the option)
$500,000$ 1 million$ 2 million$ 5 million$10 millionOther: $
6: Does Applicant collect, store or process personally identifiable or other confidential information?
YesNo
7: What is the total number of records held by Applicant excluding employee records?
8: Does Applicant have a business continuity plan in place and confirm you can up and running within:
24 hours48 hours or Within other:hours/day
9: Does Applicant have an incident response plan for network intrusions and data security breaches?
10: Does Applicant have a Privacy policy?
11: Does Applicant have a policy of shredding documents when disposing off confidential?
12: Does Applicant use firewalls to prevent unauthorized access to its networks and computer systems?
13. Does Applicant have antivirus software installed on its network and PCs?
14. Does Applicant regularly implement a written patch management process?
15. Does Application's business encrypt its critical or sensitive data at rest?
16. Is the Personal Information (PI) held on portable media devices encrypted?
17. Does Applicant conduct security awareness training for its employees?
18. Are Applicant passwords secure ( i.e not default passwords and regularly changed)?
19. Does Applicant process credit or debit card transactions?
20. Please provide the value of the average monthly payment transactions processed.
21. How frequently does Applicant back up electronic data?
DailyWeekly14 Daysother:
22. Does Applicant use a third | parthy vendor for the following services? If 'Yes', please provide the name of the thirt party(s).
NetWork Securtiy
Cloud/back-up provider
Internet service provider
Application critical software provider
payment processor
POS hardware provider
23. Has the Applicant's business carried out a risk assessment recently?
24. In the past of 5 years has the business been made aware of any cyber or data breach event that is reasonably likely to give rise to a loss or claim under such insurance policy, or have they suffered any loss, or claim being made against them?
25: STAMP DUTY SPLIT: For the purpose of calculating Stamp Duty please confirm the number of employees in the relevant State of Australia
NSW
VIC
QLD
SA
WA
TAS
ACT
NT
Overseas
We declare that the above answers, statements, particulars are true to the best of the knowledge and belief of the Applicant.
Signed:
[signature* signature-865]
Name:
Position:
Date:
