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Info-Cyber Risk Insurance Questionnaire
If the request requires immediate action please contact our staff by phone so we can support you in the timeframe you require.
866-957-KMRD (5673)
KMRD Client Contact Information
First Name
*
Last Name
*
Title
*
Phone Number
*
Email Address
*
Company Name of KMRD Client
*
Date Needed
+
Website
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Washington DC
Zip Code
*
KMRD Service Person Name or Office
General Applicant Information
Number of Years in Business
*
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100+
Annual Revenues:
*
Describe your Business / Platform:
*
0/250 words
Describe You Backup and Data Recovery System / Name of Vendor
*
0/250 words
Who is your Internet Service Provider?
*
0/250 characters
Risk Control Self Assessment
1. Do you implement virus controls and filtering on all systems?
*
Yes
No
2. Do you check for security patches to your systems at least weekly and implement them within 30 days?
*
Yes
No
3. Do you replace factory default settings to ensure your information security systems are securely configured?
*
Yes
No
4. Do you have a way to detect unauthorized access or attempts to access sensitive information?
*
Yes
No
5. Do you know what sensitive or private information is in your custody along with whose info it is, where it is and how to contact individuals if their information is breached?
*
Yes
No
6. Do you authenticate and encrypt all remote access to your network and require all such access to be from systems at least as secure as your own? Check N/A if you do not allow remote access to your systems.
*
Yes
No
N/A
7. Do you have a company policy governing security and accept use of company property?
*
Yes
No
8. Do you re-assess security threats and upgrade your risk controls in response at least yearly?
*
Yes
No
9. Do you limit access to data on a need-to-know basis?
*
Yes
No
10. Do you outsource your information security to a firm specializing in information security or have staff responsible for and trained in information security?
*
Yes
No
11. On your wireless networks; do you use security at least as strong as WPA authentication and encryption? Check N/A if you do not use wireless networks.
*
Yes
No
N/A
12. Do you control and track all changes to your network to ensure that it remains secure?
*
Yes
No
13. Do you have a prominently disclosed privacy policy?
*
Yes
No
14. At least once a year, do you provide security awareness training for everyone who accesses your network?
*
Yes
No
History of Claims and Complaints
Have you received any complaints, claims, or been subject to litigation involving matters of privacy injury, identity theft, denial of service attacks, theft of others information, damage to other networks, or others ability to rely on your network?
*
Yes
No
If Yes, please explain here.
0/250 words
Are individuals or organizations to be insured under this policy responsible for or aware of, any prior incident, circumstance, event, complaint, or litigation that could reasonably give rise to a claim, under this Policy?
*
Yes
No
If Yes, please explain here.
0/250 words
Thank you for utilizing this system. You should recieve confirmation of your request via email. A KMRD representative will reach out to you with questions if we have them. If you do not hear from us, feel free to call at
866-957-KMRD (5673) or
contactus@kmrdpartners.com
This form is for communication purposes only. The form does not bind coverage.