Privacy Security Indication Questionnaire

Privacy & Security Indication Questionnaire
Entity Name:*
Date:*
MM slash DD slash YYYY
Address:*
Street Address :*
City :*
State:*
ZIP Code:*
Business Type (Corporation, LLC, Partnership, Individual, Other):*
Year Established:*
Number of Employees Total:*
Web Address:*
Please detail all name changes, mergers and/or acquisitions in the last five years.*
Details of any additional entities to be covered (with revenues) should be attached*
Max. file size: 100 MB.
Total Gross Revenues Prior Year $*
Coming Year (Estimate) $*
Business-to-Business %*
Business-to-Customer %*
Website Derived %*
Has the applicant ever pursued or been declined for Privacy/Security coverage?*

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Operations and Information Handling
Please describe your operations and the types of confidential information handled (include electronic, paper, and employee records)*
Please estimate the # of individual confidential records maintained and describe calculation method. (To include any legally protected non-public information)*

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Incident History
During the past five years: Have you had any privacy breach incidents or complaints?*
- Yes
- No
Have any of these incidents been reported to an insurance carrier?**
- Yes
- No
Have any suits or regulatory proceedings been brought against you?*
- Yes
- No
Is any party seeking coverage aware of any fact or circumstance that could lead to a loss?*
- Yes
- No
Please attach details for any “yes” answers
Drop files here or

Max. file size: 100 MB.

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Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge.*
- Yes
- No
Signature*
Max. file size: 100 MB.
Job Title*
Date*
MM slash DD slash YYYY

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Privacy & Security Indication Questionnaire