Cyber Security Business Application Form

General Information

Full Business name of Applicant
Head office address
Business description / industry
Web site address
Date established

Risk Details

1. Revenue for the past 12 months ($)
2. Please state the approximate number of debit / credit card transactions processed in the last 12 months
3. (i) Have up to date anti virus and fire wall protection installed and operating on all computers systems.
3. (ii) Have a security policy that identifies and stipulates the types and levels of protection for all of the Applicant’s information assets, whether electronic or otherwise and whether held by the Applicant or by a person or organisation providing services to the Applicant.
3. (iii) Conducts penetration testing of the systems and actively monitor network traffic to regularly identify and assess new threats and adjust the security policy (and protection procedures) to address the new threats.
3. (iv) Conduct back up and recovery procedures on all sensitive and financial data on at least a weekly basis.
3. (v) Have written agreements in place between the Applicant and any third-party IT service provider and that such agreements confirm a level of security consummate or better to the Applicants own security.
4. Does the Applicant or any subsidiaries store sensitive information on web servers?
5. (i) Has the Applicant or any subsidiaries experienced a security breach or been required or compelled notify customers or other third parties of the release of sensitive data?
5. (ii) Has the Applicant, any subsidiaries or any person proposed for coverage under this Policy ever given notice under the provisions of any prior or current cyber security policy or similar insurance of facts or circumstances which might give rise to a claim that would fall within the scope of that cover?
5. (iii) Has the Applicant or any subsidiaries have any knowledge of any loss payments, fines or penalties being made on behalf of any Applicant or any person proposed for coverage under any cyber security policy or similar insurance?


This proposal must be filled in by the Applicant's Chairman of the Board, Managing Director, or Chief Executive Officer.