Note to the proposer:

This application form is for companies with revenue of less than £50m who are looking for cyber insurance limits of £5m or below. If you would like further information about the cover available or assistance with completing this form, then please contact us on 0121 4545100 or email us at

Signing or completing this proposal does not bind the Proposer, or any individual or entity he or she is representing to complete this insurance. Please provide by addendum on the Company headed paper of the Proposer any supplementary information which is material to the response of the questions herein, and/or complete answers to the listed questions if they do not fit in the space provided on the application. For the purposes of this proposal form, ‘Proposer’ means the entity stated below and all its subsidiaries to be covered. All answers should be given as a group response i.e. if any subsidiary company has different responses these should be provided separately on your headed paper.

Basic Company Details

Company Name: (required)

Primary Address (Address, County, Postcode, Country):

Primary Industry Sector:

Description of Business Activities:

Website Address:

Date Established:

Last Complete Financial Year Revenue:

Revenue from US Sales (%):

Primary Contact Details

Contact Name: (required)

Position: (required)

Email: (required)

Contact Telephone: (required)

Coverage Required

Please indicate the limit you require:

Cyber & Privacy Liability:







Previous Cyber Incidents

Please tick all the boxes below that relate to any cyber incident that you have experienced in the last two years (there is no need to highlight events that were successfully blocked by security measures):

 Cyber Crime

 Cyber Extortion

 Data Loss

 Denial of Service Attack

 IP Infringement

 Malware Infection

 Privacy Breach


 Other (please specify)


By signing this form you agree that the information provided is both accurate and complete and that you have made reasonable attempts to ensure this is the case by asking the appropriate people within your business.

I declare that the statements and particulars in this declaration are true and that no material facts have been misstated. I agree that this declaration together with any other information supplied shall form the basis of the Contract of Insurance effected thereon. I undertake to inform the insurers of any material alteration to those facts occurring before the completion of the contract of insurance. A material fact is one which would influence the acceptance or assessment of the risk. I also declare to have read the applicable wording and fully understand its scope, exclusions and limitations.




Date (DD/MM/YY):


Quote valid 14 days from date of declaration