Application Form | Cyberboxx

APPLICATION FORM - Cyber, Data and Policy

Notice: The policy for which these questions are made is a claims made and reported policy subject to its terms. The questions contained herewith pertain to all persons or entities seeking insurance, and not just the signatory.

Company Details

Company Name

Client Contact Name

Contact Email (documents will be sent here)

Address

Website

Gross Annual Revenue

What percentage of Revenue is generated from the USA?

Select your preferred Cyberboxx Option

Option 1 - $250,000 Aggregate limit including optional Cyber Deception $100,000 Limit

Option 2 - $1,000,000 Aggregate limit including optional Cyber Deception $100,000 Limit

Option 3 - $2,000,000 Aggregate limit including optional Cyber Deception $250,000 Limit

Please read these questions carefully. You must provide us with accurate and complete information. Failure to do so may affect the validity of the policy or whether the policy responds to any claim in full or at all.

Security controls:

The applicant has firewalls in place and have installed antivirus software on all your computers and laptops that check for updates at least monthly.

The applicant regularly back-ups critical data for on-premises systems (at least monthly) AND stores off-site OR critical data is stored exclusively with cloud software providers.

For Cyber Deception optional coverage (only):

All employees responsible for wire transfer of funds are provided training to detect and prevent fraud, social engineering and similar scams?

Before processing a wire transfer of funds OR changing vendor account details, the applicant confirms the request by a secondary means of communication?

Important -

By entering your name and email, you agree that all information provided to BOXX Insurance to generate this insurance policy is accurate and true. Entering your name and email address is akin to signing any legal document and you will be bound to all acknowledgements provided herein and that you have the authority to bind your company to this agreement.

Thanks for submitting!