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Test Cyber Form
Service Request (Cyber)
Name
*
Email
*
Phone
*
Firm Name
Website Domain(s)
Address
Projected Next Year Revenue
Last Fiscal Year End Revenue
Within the last 3 years has Named Insured suffered any cyber incidents resulting in a claim in excess of $25,000?
Yes
No
Is Named Insured aware of any circumstances that could give rise to a claim under this insurance policy?
Yes
No
How many customer PII or PHI records does Named Insured have?
0-100,000
100,000-250,000
250,000-500,000
500,000-1m
>1m
Number of Employees
Does insured maintain at least weekly backups of all sensitive or otherwise critical data and all critical business systems offline or on a separate network?
Yes
No
Where is your data backup stored? (check all that apply)
Internally
Externally
Cloud
Does Named Insured require a secondary means of communication to validate the authenticity of: Funds transfer requests (ACH, wire, etc.) before processing a request in excess of $25,000?
Yes
No
Does Named Insured require a secondary means of communication to validate the authenticity of Any request to change banking details (ACH, wire, payroll distribution, etc.)?
Yes
No
Do you enforce Multi-Factor Authentication (MFA) for email?
Yes
No
N/A – No remote access allowed
Do you enforce Multi-Factor Authentication (MFA) for Virtual Private Network (VPN)?
Yes
No
N/A – No VPN allowed
Do you enforce Multi-Factor Authentication (MFA) for Remote Desktop Protocol (RDP), RDWeb, RD Gateway, or other remote access?
Yes
No
N/A – No remote access allowed
Do you enforce Multi-Factor Authentication (MFA) for Network/cloud administration or other privileged user accounts?
Yes
No
On administrative accounts and all cloud services where supported
Does Named Insured enable disk encryption on laptops, desktops, and other portable media devices?
Yes
No
If you are human, leave this field blank.
Submit
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