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
If confidential information is stored on laptops, flash drives and other mobile devices, is the information stored in an encrypted format?
Is data "at rest" (servers, etc.) stored in an encrypted format?
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.
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.
Sign by certifying that the above statements are true to the best of your knowledge:
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.