BAR ASSOCIATION CYBER INSURANCE FORM
Company Information
Please complete the following details for the entire company or group (including all subsidiaries) that is applying for the insurance policy.
Company Name
Company Primary Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip/ Postal Code
Primary Industry Sector
Description of Business Activities
Website
Date Established
Last Complete Financial Year Revenue
Company Contact Information
Please Enter Primary Contact Information in this section.
Contact Name
First
Last
Position
Phone Number
Email
Coverage
Please indicate which limit options you would like to receive a quotation for (if cover is not required for a particular area please leave blank).
Coverage Required
$500k
$1M
$2M
$3M
Cyber Crime
Cyber Crime covers of $250k is included in the coverage amount.
$250K
Have you had any previous cyber incidents?
Yes
No
If you selected yes, did the incident(s) have a direct financial impact upon your business of more than $10,000?
Yes
No
If you checked yes above, please provide more information below, including details of the financial impact and measures taken to prevent the incident from occurring again.
Escrow
Please confirm whether you offer any escrow services relating to real estate transactions.
Yes
No
Consent
IMPORTANT NOTICE: Bar Association Cyber will use this information solely for the purposes of providing insurance services and may share your data with third parties in order to do this. We may also use anonymized elements of your data for the analysis of industry trends and to provide benchmarking data.
Please check this box to validate your submission of this form. By submitting this form you agree that the information provided is both accurate and complete and that you made all reasonable attempts to ensure this is the case by asking the appropriate people within your business.
Please confirm that before any change is made to any client account, you obtain authorization from the client via an authentication method which is different from the original method you used to confirm the identification of the client.
Yes
No
Please confirm that before you transfer any client funds you obtain authorization from the client via an authentication method different from the original method you used for identification of the client.
Yes
No
Please confirm multi-factor authentication is always enabled on all of your email accounts.
Yes
No
Do you use a secure platform for all wire instructions/transfers in place of standard email instruction?
Yes
No
If yes, please provide details.
Please confirm whether you provide all clients with a written warning that is they receive a request via email to make any change to their account or to transfer any funds that they must not respond to the email and they must contact you immediately.
Yes
No
Please state, on average, how many transactions you process per month.
Please state the average value of transactions you process.
Please state the amount of the largest transaction you have processed.
Please state whether you have dual authorization procedures in place for electronic fund transfers.
Yes
No
If "yes" please provide details. If "no" please explain why.
Please provide details of your crime policy (if purchased) including limit, deductible, and insurance carrier.
Consent
IMPORTANT NOTICE: Bar Association Cyber will use this information solely for the purposes of providing insurance services and may share your data with third parties in order to do this. We may also use anonymized elements of your data for the analysis of industry trends and to provide benchmarking data.
Please check this box to validate your submission of this form. By submitting this form you agree that the information provided is both accurate and complete and that you made all reasonable attempts to ensure this is the case by asking the appropriate people within your business.
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