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Cyber Liability Questionnaire

* Indicates required field

Company Name *

Email *

Company Contact Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Tell us about your business: Indsutry, Products & Services *

Does your business have any of the following? (check all that apply) *

A Firewall Anti-virus software Does your hiring process include a criminal bacground check A written privacy or security policy Do you have a program in place to test your security / privacy controls? Do you allow employees to download personal or confidenital information belonging to 3rd parties Do you encrypt your and/or your customer's data? If you accept credit cards, are you PCI compliant?

Gross Sales *

# of Client Records *

Do you retain any of the following information: (Check all that apply) *

Credit Card Information Social Security Numbers Medical Information Employee / HR Information Bank Accounts and/or Records Intellectual Property of Others

In the last 3 years, have you received any claims or complaints with respect to privacy, breach of information or network security? *

Have you been subject to any governmental action, investigation or subpeona regardsing any alleged bilation of a privacy law? *

Has your company ever experienced a ransomware attack? *

Are you aware of any circumstance that could give rise to a claim agianst yoru company for data breach, hack, etc? *

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