LGIT has partnered with Arthur J. Gallagher Risk Management Services to bring a new value-added benefit at no cost to our members. With the LGIT Cyber Liability Insurance Program, our members can better protect themselves from liability and out-of-pocket expenses associated with a data breach.

This insurance benefit will be provided at no cost to our individual members for the 2016 policy period, however, in order to qualify for coverage, LGIT members must complete the five-question LGIT Cyber Insurance Application below before June 15, 2016 and be accepted by underwriting, in order to be added to the master policy effective 7/1/2016.

Coverage is provided on a non-admitted basis by Indian Harbour Insurance Company, trading as XL Catlin. Indian Harbour’s excellent financial stability is recognized by AM Best with a rating of “A” (Excellent) XV. A summary of the coverage afforded under the LGIT policy is provided below. This is not a complete list of coverage – policy specimens are available upon request. For additional information, please contact Mr. Scott Soderstrom, Director of Underwriting, 800-673-8231.

STEP ONE - APPLICANT INFO

Entity Name:

Your Name

Address

City

State

Zip Code

Email Address

Phone

Budget

Population

Desired Effective Date

PRODUCT INFO

• LGIT Cyber Insurance Overview

STEP TWO - UNDERWRITING INFO

This is not a guarantee of coverage. In order to confirm eligibility for the program, and to determine overall interest in securing coverage for LGIT members, please answer the questions below:

1. Do you have anti-virus software installed and enabled on all desktops and servers (excluding database servers) and is it updated on a regular basis? Do you also have firewalls installed on all external gateways? Finally, do you take regular back-ups (at least weekly) of all critical data?
   Note: Check yes only if all apply

   Yes
   No

2. If confidential information is stored on laptops, flash drives and other mobile devices, is the information stored in an encrypted format?

   Yes
   No

3. Is data "at rest" (servers, etc.) stored in an encrypted format?

   Yes
   No

4. Have you suffered a claim or loss in the last five years, in relation to the risks that this proposal relates to? If yes, please describe via the space below.

   Yes
   No
   
   

5. Are you aware of any circumstances or complaints against you in relation to data protection or security, PII (Personally Identifiable Information), PHI (Protected Health Information) or any actual or potential security violations or breaches either currently or in the past five years? If yes, please describe via the space below.

   Yes
   No
   
   

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Sign by certifying that the above statements are true to the best of your knowledge:

Submit

THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED. COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICATIONS WILL BE UNDERWRITTEN ON AN INDIVIDUAL BASIS TO DETERMINE ELIGIBILITY FOR INCLUSION IN THE PROGRAM. ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION WITH THIS APPLICATION ARE HEREBY INCORPORATED INTO THIS APPLICATION AND MADE A PART HEREOF.