Cyber Insurance Claim Form

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Insured Name*

Policy number*

Email*

Phone Number*

Third party details (if applicable)

Business Name (optional)

Phone (optional)

Address (optional)

Insurance Product*

Please advise their involvment in this event (optional)

Incident details

Have you been notified by Law Enforcement or your Bank about a potential data breach? (YES / NO If Yes, provide details.)*

Are you being requested to perform a Payment of Card Industry (PCI) Forensic Investigation? (YES / NO If Yes, provide details.)*

Do you believe sensitive data has been compromised and that you need to confirm/deny that a data breach has taken place? (YES / NO If Yes, provide details)*

Have you received a written demand or notice of claim from a third party seeking compensation or other legal remedy? (YES / NO If Yes, provide details)*

Please explain the circumstances of the Cyber Event*

Insurance history

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)*

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)*

Additional information (optional)

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