Cyber Insurance Application
Organization contact information
Name
*
First Name
Last Name
Current Email Address
*
example@example.com
Is this person willing to serve as Cowbell's designated Information Security Contact?
*
Yes
No
Main business phone number
*
Please enter a valid phone number.
Tell us about your business
Legal Business Name
*
What type of business do you operate?
*
Please Select
Government entity
Private entity
Publicly traded entity
Non-profit
Investment fund
Describe your business by industry / type
*
Business Address
*
Street Address
Street Address Line 2
City
*
City
State
*
Please Select
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
State
Year Established
*
Please enter year when your business started
Zip Code
*
Zip Code
Projected Revenue
*
Please enter projected 12 month revenue for your business
Number of Employees
*
Please enter number of employees at your business
Security Info
Have you ever had any cyber insurance claim(s)?
*
Yes
No
Does your organization encrypt all emails, mobile and computing devices containing sensitive information sent to external parties?
*
Yes
No
Does your organization have sensitive information stored on the cloud?
*
Yes
No
Social Engineering Coverage: Does your organization prevent unauthorized employees from initiating wire transfers?
*
Yes
No
Social Engineering Coverage: Does your organization authenticate funds transfer requests (e.g.by calling a customer to verify the request at a predetermined phone number)?
*
Yes
No
Social Engineering Coverage: Does your organization verify vendor/supplier bank accounts before adding to their accounts payable systems?
*
Yes
No
Submit your application to Lockton Affinity for review
Privacy
Terms
Terms and Conditions
*
I attest that the information presented is a complete, true and accurate representation on this business and understand that any fraudulent intent is subject to criminal and civil penalties.
I have read Cowbell Insurance Agency Terms of Use, Insurance Fraud Warnings, and State-Specific Signature-Bearing Endorsements.
Please verify that you are human
*
Submit
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