Skip to content
Cyber Cover PlusCyber Cover Plus
  • Home
  • About Us
  • Contact Us
  • Request a quote

Step 1 of 5

20%

IMPORTANT NOTICES

Please read the following before proceeding to complete this Proposal Form.

Your Duty of Disclosure

Before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, that may affect our decision to insure you and on what terms.
You have this duty until we agree to insure you.
You have the same duty before you renew, extend, vary or reinstate an insurance contract. You do not need to tell us anything that:

a. reduces the risk we insure you for;
b. is common knowledge;
c. we know or should know as an insurance company; or
d. we waive your duty to tell us about.

If you do not tell us something

If you do not tell us something you are required to, we may cancel your policy or reduce the amount we shall indemnify you if you make a claim, or both.
If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the policy as if it never existed.

Completing this Proposal Form

• Please answer all questions giving full and complete answers.
• It is the duty of the Applicant to provide all information that is requested in the Proposal Form as well as to add additional relevant facts. Note: A relevant fact is a known fact and/or circumstance that may influence in the evaluation of the risk by the Insurer. If you have any doubts about what a relevant fact is, please do not hesitate to contact your Broker.
• If the space provided on the Proposal Form is insufficient, please use a separate signed and dated sheet in order to provide a complete answer to any question.
• The Proposal Form must be completed, signed and dated by a person who must be of legal capacity and authorised for the purpose of requesting this insurance for the organisation who acts as the Applicant.

This Proposal Form DOES NOT BIND the Applicant or the Insurer to complete the insurance but will form part of any insurance.

Privacy Collection Statement

At DUAL Australia Pty Ltd (DUAL), we are committed to protecting your privacy and complying with the Privacy Act 1988 (Cth) (‘Privacy Act’).

We use your information to assess the risk of providing you with insurance, provide quotations, issue policies and assess claims, on behalf of the insurers we represent. We also use your information to administer any policies we have issued to you and may do so by mail or electronically, unless you tell us that you do not wish to receive electronic communications. If you do not provide us with full information, we may not be able to provide insurance or assess a claim. If you provide us with information about someone else, you must obtain their consent to do so.

We provide your personal information to the insurer we represent when we issue and administer your insurance. When providing a quotation or insurance terms, we will tell you if the insurer is overseas and if so, where they are. We may also provide your information to your broker and our contracted third-party service providers (e.g. claims management companies).

We are part of Howden Group Holdings Limited and may provide your information to UK based Group entities who provide us with business support services. If a recipient is not regulated by laws which protect your information in a way that is similar to the Privacy Act, we will take reasonable steps to ensure that they protect your information in the same way we do or seek your consent before disclosing your information to them. We do not trade, rent or sell your information.

Our Privacy Policy contains more information about how to access and correct the information we hold about you and how to make a privacy related complaint, including how we will deal with it. By providing us with your personal information, you consent to its collection and use as outlined above and in our Privacy Policy.

Consent(Required)

Details of Applicant

Insured’s Registered Address:
Please provide a detailed description of all business activities including the activities of any related entities.
Include all principals, partners, directors, and employees (full time, part time and casual staff, interns and volunteers).
Leave it empty if you don't have website

General Questions

Does the Insured currently have Cyber insurance in place?
If NO, would the Insured like to change their retroactive date from policy inception to unlimited for an additional 30% premium?
After enquiry of all Partners, Principals, Directors, Officers, Trustees and Senior Managers:
Have there been any claim(s) made against the Insured or any loss or expense incurred* which might fall within the terms of this insurance cover? OR b. Have any circumstances occurred which may give rise to a claim against the Insured or result in any loss or expense incurred* which might fall within the terms of this insurance cover? *Incurred means any settlement made, legal fees, defence costs or reserved amounts.
Is the Insured aware of any matter that is reasonably likely to give rise to any loss or claim under such insurance, or has the Insured suffered any loss or any claim including but not limited to a regulatory, governmental or administrative action brought against the Insured, or any investigation or information request concerning any handling of personally identifiable information?
Has the Insured or any Partners, Principals, Directors, Officers, Trustees and Senior Managers ever been declined this type of insurance, or had similar insurance cancelled, or had an application for renewal declined (other than insurer exiting that area of insurance), or had special terms or restrictions imposed?
Is the Insured domiciled in Australia with no subsidiaries outside Australia or New Zealand?
If NO, please confirm
Is the Insured domiciled in Australia?
Where are the Insured’s overseas subsidiaries?
Please specify below in which countries the Insured’s subsidiaries are located and indicate the percentage of total revenue derived.
Subsidiary
Name Country
Revenue %
 

What is the Insured’s breakdown of turnover?

We use this information to apportion the payment of stamp duty across different states and territories where the insured operates their business. This is important because for certain policies we offer which need to have stamp duty apportioned across different states and territories.
*If the Insured has declared Overseas Turnover, please complete the below table to answer the following: a. From which country or countries is the Overseas Turnover derived? b. What activities are conducted overseas? c. How many Personally Identifiable Information (PII) records are held Overseas?
List
Country(ies)
Percentage of Total Turnover
Activities
Personally Identifiable Information (PII) Records
 
Is the Insured exempt from GST?
Is the Insured exempt from Stamp Duty?
If YES, please confirm the following
I declare that the Insured is relying on a stamp duty exemption (for example a charity organisation exemption) in relation to this policy. I have obtained a copy of the exemption certificate(s) or declaration(s) and any other supporting documentation to verify this exemption and I will provide a copy to DUAL on binding or upon request.

Cyber Liability & Privacy Protection Specific Questions

Does the Insured use operating systems with embedded firewalls and anti-virus protection software (such as Windows or Mac OS X), or run commercially licenced separate firewall or anti-virus protection software?
Are all mobile devices (such as laptops, tablets, smartphones and memory sticks) password protected?
Is the insured compliant with Payment Card Industry Standards (if applicable), as set out by the PCI Security Standards Council (PCI SSC)?
Compliance with PCI Standards is required for all entities that store, process or transmit cardholder data. For more information on this please visit www.pcisecuritystandards.org. If the PCI Standards do not apply to the Insured, please answer “YES” to this question.
Does the Insured outsource any part of their network, including storage?
An Insured may hold various pieces of personal information for one client (for example name, address, and age), and that information is counted as one record.
Does the Insured (directly or by re-selling such service) provide, operate, administer or maintain any cloud hosting services, website hosting services or Internet Service Provider (ISP) services, to or on behalf of third parties?
Is multi-factor authentication required for any remote access to the Insured’s systems (including webmail, Citrix desktop, Cloud based applications, or Remote Desktop Protocol “RDP”)?
Does the Insured have an e-mail filtering system (e.g. MimeCast or equivalent) in place that is activated for all email accounts?
Is more than 25% of the Insured’s revenue derived from the USA or Canada?
Does the Insured wish to include cover for Social Engineering, Phishing & Cyber Fraud for an additional premium up to 25%?
For further information regarding this Optional Extension, please visit our website.
If YES please confirm the following.
Are all requests to establish/create or alter supplier and customer details including bank account details, independently verified with a known contact, either in person or via a telephone call, for authenticity?
Does the Insured ensure that at least two members of staff authorise any transfer of funds, signing of cheques (above $2,000) and the issuance of instructions for the disbursement of assets, funds or investments?
Does the Insured maintain procedures for the provision of written training materials to all Employees regarding the dangers of Social Engineering Fraud, Phishing, Phreaking and Cyber Fraud which incorporate regular review?
Does the Insured maintain procedures for changing passwords for all online accounts and banking platforms maintained by the Insured at least every 45 days and that the password protocols accord with industry best practice, or adopt two factor authentication?
Does the Insured wish to include cover for Contingent Business Interruption for an additional 10% premium? (Available on Platinum only)
If the Insured’s occupation is retail / wholesale - Does the Insured generate more than 50% of their revenue through online or e-commerce activities?

Declaration

SIGNING THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR THE INSURER TO COMPLETE THIS INSURANCE The undersigned declares that the statement and particulars in this Proposal Form are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agree that should any of the information given by us alter between the date of this proposal and the inception date of the insurance to which this proposal relates, the undersigned will give immediate notice thereof. The undersigned agrees that the Underwriters may use and disclose our personal information in accordance with the ‘Privacy Collection Statement’ above. The undersigned acknowledges that they have read this Proposal Form, including all Important Notices, as well as the policy wording and associated endorsements and are satisfied with the coverage provided, including the limitations and restrictions on coverage. The undersigned agrees that this Proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.

Code of Conduct

Financial Services Guide

Duty of Disclosure

Privacy

Compliance

Copyright © Cyber Cover Plus - a division of IMC Insurance Brokers | Level 1, 251 - 253 Malvern Road South Yarra VIC 3141 | Telephone: 1300 127 587
  • Home
  • About Us
  • Contact Us
  • Request a quote