BAR ASSOCIATION CYBER INSURANCE FORM
Name
Company Name
Please complete the following details for the entire company or group (including all subsidiaries) that is applying for the insurance policy.
Primary Industry Sector
Description of Business Activites
Website Address
Company Primary Address
City
State
- Select Province/State -
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
====================
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
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
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Date Established
Last Complete Financial Year Revenue
Contact Name
Please Enter Primary Contact Information in this section.
Email
Position
Phone Number
Coverage Required
$500k
$1M
$2M
$3M
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).
Cyber Crime
$250K
Cyber Crime covers of $250k is included in the coverage amount.
Have you had any previous cyber incidents?
Yes
No
If you selected any of the items above, 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
Yes
No
Please confirm whether you offer any escrow services relating to real estate transactions.
