Cyber Liability Insurance Application - Alliance for Contractors

CYBER LIABILITY INSURANCE APPLICATION

Digital Security Coverage for Contractor Data Breaches and Cyber Attacks

1. COMPANY INFORMATION
Legal Business Name:
DBA/Trade Name:
Business Address:
City, State, ZIP:
Phone Number:
Email:
Federal Tax ID:
Years in Business:
Number of Employees:
Annual Revenue:
Alliance Membership ID:
Member Since:
2. BUSINESS OPERATIONS & TECHNOLOGY USAGE

Primary Construction Services (check all that apply):

General Contracting
Electrical
Plumbing
HVAC
Roofing
Flooring
Landscaping
Specialty Trade
Other Services:

Technology Systems Used (check all that apply):

Project Management Software
Accounting/QuickBooks
CRM Systems
Cloud Storage
Mobile Apps
Email Systems
Website/E-commerce
Remote Access Tools
Number of Computers/Devices:
Network Type:
3. DATA STORAGE & SECURITY MEASURES

Types of Data Stored (check all that apply):

Customer Personal Information
Credit Card/Payment Data
Employee Records
Financial Records
Project Plans/Blueprints
Vendor Information
Health/Safety Records
Insurance Information
Estimated # of Customer Records:
Data Backup Frequency:

Current Security Measures in Place (check all that apply):

Firewall Protection
Antivirus Software
Data Encryption
Multi-Factor Authentication
Regular Software Updates
Employee Security Training
Written Security Policies
Professional IT Support
IT Security Provider:

🛡️ Alliance Advantage: Enhanced Security Assessment

As an Alliance member, you have access to our comprehensive cybersecurity assessment tools and employee training programs. Complete your free security audit to potentially qualify for premium discounts up to 15%.

I want to schedule a free Alliance cybersecurity assessment
Enroll my team in Alliance cyber security training program
4. PREVIOUS CYBER INCIDENTS HISTORY
Have you experienced any cyber incidents in the past 5 years?

If YES, provide details for each incident:

Date Type of Incident Description Financial Impact Resolution
Any pending cyber liability claims?
If Yes, explain:
5. COVERAGE REQUIREMENTS & LIMITS

Requested Coverage Limits:

Coverage Type Requested Limit Deductible
Data Breach Response
Business Interruption
Cyber Extortion

Additional Coverage Options:

Social Engineering Fraud
Funds Transfer Fraud
Regulatory Defense & Penalties
Media Liability
Technology E&O
System Damage & Restoration
6. RISK ASSESSMENT QUESTIONS
Do you process credit card payments?
Are you PCI DSS compliant?
Do employees work remotely or use personal devices?
Do you use cloud-based services for data storage?
Do you have a written incident response plan?
How often do you conduct security training?
Additional Risk Information:

📚 Alliance Cyber Training Program

Enhance your cyber security posture with our comprehensive training modules designed specifically for contractors:

  • Phishing Recognition and Prevention
  • Safe Data Handling for Construction Projects
  • Mobile Device Security for Field Workers
  • Password Management Best Practices
  • Incident Response for Small Contractors
Enroll all employees in Alliance cyber training (Premium discount eligible)
APPLICANT'S DECLARATION AND SIGNATURE

I hereby declare that the information provided in this application is true, complete, and accurate to the best of my knowledge and belief. I understand that any material misrepresentation or omission may void coverage. I acknowledge that this application does not bind coverage and that coverage is subject to underwriting approval and policy terms and conditions.

I understand that as an Alliance for Contractors member, I am eligible for enhanced cybersecurity resources, training programs, and potential premium discounts based on security assessment results.

Preferred Contact Method for Quote:

Email
Phone
Mail
Alliance Portal

Applicant's Signature:

Print Name:

Title:

Date:

Alliance for Contractors | Cyber Liability Insurance Application

For questions or assistance, contact your Alliance representative at (555) 123-4567 or [email protected]

Member Portal: www.alliancecontractors.com/cyber-coverage