Contact Name*
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Contact Email*
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Contact Phone*
Please Enter your Phone Number
Insured Name*
Enter Insured Name
Address*
Please enter the full address for the main business to be used for all policy documentation.
Town or City*
Zip Code*
State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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
Employees*
Please provide details of total number of full-time employees as of time of completing this application. Do not include the owner in this number if they are a sole proprietor.
Main Industry* Accommodation and Food Services [72] Administrative, Support and Waste Management Services [56] Agriculture, Forestry, Fishing and Hunting [11] Arts, Entertainment, and Recreation [71] Construction [23] Educational Services [61] Finance and Insurance [52] Heath Care and Social Assistance [62] Information Technology, Media, and Telecoms [51] Management of Companies and Enterprises [55] Manufacturing [C] Mining, Quarrying, and Oil and Gas Extraction [21] Miscellaneous Retail [59] Other Services (except Public Administration) [81] Professional, Scientific, and Technical Services [54] Public Administration [92] Real Estate and Rental and Leasing [53] Transportation and Storage [H] Utilities [22] Wholesale Trade [42]
Please select the business description which most closely reflects the insured's main business activity. These activities are based on standard industrial classification codes.
Detailed Activity* Drinking Places (Alcoholic Beverages) [7224] Full-Service Restaurants [7221] Limited-Service Eating Places [7222] Rooming and Boarding Houses [7213] RV (Recreational Vehicle) Parks and Recreational Camps [7212] Special Food Services [7223] Traveler Accommodation [7211]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Business Support Services [5614] Employment Services [5613] Facilities Support Services [5612] Investigation and Security Services [5616] Office Administrative Services [5611] Other Support Services [5619] Remediation and Other Waste Management Services [5629] Services to Buildings and Dwellings [5617] Travel Arrangement and Reservation Services [5615] Waste Collection [5621] Waste Treatment and Disposal [5622]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Aquaculture [1125] Cattle Ranching and Farming [1121] Fishing [1141] Forest Nurseries and Gathering of Forest Products [1132] Fruit and Tree Nut Farming [1113] Greenhouse, Nursery, and Floriculture Production [1114] Hog and Pig Farming Hunting and Trapping [1142] Logging [1133] Oilseed and Grain Farming [1111] Other Animal Production [1129] Other Crop Farming [1119] Poultry and Egg Production [1123] Sheep and Goat Farming [1124] Support Activities for Animal Production [1152] Support Activities for Crop Production [1151] Support Activities for Forestry [1153] Timber Tract Operations [1131] Vegetable and Melon Farming [1112]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Agents and Managers for Artists, Athletes, Entertainers, and Other Public Figures [7114] Amusement Parks and Arcades [7131] Gambling Industries [7132] Independent Artists, Writers, and Performers [7115] Museums, Historical Sites, and Similar Institutions [7121] Other Amusements and Recreation Industries [7139] Performing Art Companies [7111] Promoters of Performing Arts, Sports, and Similar Events [7113] Spectator Sports [7112]]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Building Equipment Contractors [2382] Building Finishing Contractors [2383] Foundation, Structure, and Building Exterior Contractors [2381] Highway, Street, and Bridge Construction [2373] Land Subdivision [2372] Nonresidential Building Construction [2362] Other Heavy and Civil Engineering Construction [2379] Other Specialty Trade Contractors [2389] Residential Building Construction [2361] Utility System Construction [2371]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Business Schools and Computer and Management Training [6114] Colleges, Universities, and Professional Schools [6113] Educational Support Services [6117] Elementary and Secondary Schools [6111] Junior Colleges [6112] Other Schools and Instructions [6116] Technical and Trade Schools [6115]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Activities Related to Credit Intermediation [5223] Agencies, Brokerages, and Other Insurance Related Activities [5242] Depository Credit Intermediation [5221] Insurance and Employee Benefit Funds [5251] Insurance Carriers [5241] Monetary Authorities-Central Bank [5211] Nondepository Credit Intermediation [5222] Other Financial Investment Activities [5239] Other Investment Pools and Funds [5259] Securities and Commodity Contracts Intermediation and Brokerage [5231] Securities and Commodity Exchanges [5232]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Child Day Care Services [6244] Community Care Facilities for the Elderly [6233] Community Food and Housing, and Emergency and Other Relief Services [6242] General Medical and Surgical Hospitals [6221] Home Health Care Services [6216] Individual and Family Services [6241] Medical and Diagnostic Laboratories [6215] Nursing Care Facilities [6231] Offices of Dentists [6212] Offices of Other Health Practitioners [6213] Offices of Physicians [6211] Other Ambulatory Health Care Services [6219] Other Residential Care Facilities [6239] Outpatient Care Centers [6214] Psychiatric and Substance Abuse Hospitals [6222] Residential Mental Retardation, Mental Health and Substance Abuse Facilities [6232] Specialty (except Psychiatric and Substance Abuse) Hospitals [6223] Vocational Rehabilitation Services [6243]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Cable and Other Subscription Programming [5152] Data Processing, Hosting, and Related Services [5182] Motion Picture and Video Industries [5121] Newspaper, Periodical, Book, and Directory Publishers [5111] Other Information Services [5191] Other Telecommunications [5179] Radio and Television Broadcasting [5151] Satellite Telecommunications [5174] Software Publishers [5112] Sound Recording Industries [5122] Wired Telecommunications Carriers [5171] Wireless Telecommunications Carriers (except Satellite) [5172]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Management of Companies and Enterprises [5511]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Manufacture of basic metals [24] Manufacture of basic pharmaceutical products and pharmaceutical preparations [21] Manufacture of beverages [11] Manufacture of chemicals and chemical products [20] Manufacture of coke and refined petroleum products [19] Manufacture of computer, electronic and optical products [26] Manufacture of electrical equipment [27] Manufacture of fabricated metal products, except machinery and equipment [25] Manufacture of food products [10] Manufacture of furniture [31] Manufacture of leather and related products [15] Manufacture of machinery and equipment n.e.c. [28] Manufacture of motor vehicles, trailers and semi-trailers [29] Manufacture of other non-metallic mineral products [23] Manufacture of other transport equipment [30] Manufacture of paper and paper products [17] Manufacture of rubber and plastics products [22] Manufacture of textiles [13] Manufacture of tobacco products [12] Manufacture of wearing apparel [14] Manufacture of wood and of products of wood and cork, except furniture; manufacture of articles of straw and plaiting materials [16] Other manufacturing [32] Printing and reproduction of recorded media [18] Repair and installation of machinery and equipment [33]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Coal Mining [2121] Metal Ore Mining [2122] Nonmetallic Mineral Mining and Quarrying [2123] Oil and Gas Extraction [2111] Support Activities for Mining [2131]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Retail Store [5900]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Courier activities [532] Freight air transport [512] Inland water transport [502] Other land transport [492] Passenger air transport [511] Postal activities [531] Sea and coastal water transport [501] Support activities for transportation [522] Transport via pipeline [493] Transport via railways [491] Warehousing and storage [521]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Automotive Repair and Maintenance [8111] Business, Professional, Labor, Political, and Similar Organizations [8139] Civic and Social Organizations [8134] Commercial and Industrial Machinery and Equipment (except Automotive and Electronic) Repair and Maintenance [8113] Death Care Services [8122] Drycleaning and Laundry Services [8123] Electronic and Precision Equipment Repair and Maintenance [8112] Grantmaking and Giving Services [8132] Other Personal Services [8129] Personal and Household Goods Repair and Maintenance [8114] Personal Care Services [8121] Private Households [8141] Religious Organizations [8131] Social Advocacy Organizations [8133]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Accounting, Tax Preparation, Bookkeeping, and Payroll Services [5412] Advertising, Public Relations, and Related Services [5418] Architectural, Engineering, and Related Services [5413] Computer Systems Design and Related Services [5415] Legal Services [5411] Management, Scientific, and Technical Consulting Services [5416] Other Professional, Scientific, and Technical Services [5419] Scientific Research and Development Services [5417] Specialized Design Services [5414]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Administration of Economic Program [9261] Administration of Environmental Quality Programs [9241] Administration of Housing Programs, Urban Planning, and Community Development [9251] Administration of Human Resource Programs [9231] Executive, Legislative, and Other General Government Support [9211] Justice, Public Order, and Safety Activities [9221] National Security and International Affairs [9281] Space Research and Technology [9271]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Activities Related to Real Estate [5313] Automotive Equipment Rental and Leasing [5321] Commercial and Industrial Machinery and Equipment Rental and Leasing [5324] Consumer Goods Rental [5322] General Rental Centers [5323] Lessors of Nonfinancial Intangible Assets (except Copyrighted Works) [5331] Lessors of Real Estate [5311] Offices of Real Estate Agents and Brokers [5312]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Electric Power Generation, Transmission and Distribution [2211] Natural Gas Distribution [2212] Water, Sewage and Other Systems [2213]
Please select the detailed activity that most closely matches the primary business activity.
Detailed Activity* Apparel, Piece Goods, and Notions Merchant Wholesalers [4243] Beer, Wine, and Distilled Alcoholic Beverage Merchant Wholesalers [4248] Chemical and Allied Products Merchant Wholesalers [4246] Drugs and Druggists Sundries Merchant Wholesalers [4242] Electrical and Electronic Goods Merchant Wholesalers [4236] Farm Product Raw Material Merchant Wholesalers [4245] Furniture and Home Furnishing Merchant Wholesalers [4232] Grocery and Related Product Merchant Wholesalers [4244] Hardware, and Plumbing and Heating Equipment and Supplies Merchant Wholesalers [4237] Lumber and Other Construction Materials Merchant Wholesalers [4233] Machinery, Equipment, and Supplies Merchant Wholesalers [4238] Metal and Mineral (except Petroleum) Merchant Wholesalers [4235] Miscellaneous Durable Goods Merchant Wholesalers [4239] Miscellaneous Nondurable Goods Merchant Wholesalers [4249] Motor Vehicle and Motor Vehicle Parts and Supplies Merchant Wholesalers [4231] Paper and Paper Product Merchant Wholesalers [4241] Petroleum and Petroleum Products Merchant Wholesalers [4247] Professional and Commercial Equipment and Supplies Merchant Wholesalers [4234] Wholesale Electronic Markets and Agents and Brokers [4251]
Please select the detailed activity that most closely matches the primary business activity.
Total Revenue*
Please enter the total revenue from the insured's last completed financial year. If this is the first year in business, then please enter an estimate for this year's revenue.
Privacy Liability Limit* $500,000 Annual Aggregate $1,000,000 Annual Aggregate $2,000,000 Annual Aggregate
Please select the limit required for the privacy liability and cyber liability insuring clauses. Please note that this is a mandatory part of the cover.
Breach Notification Limit* Not Required $100,000 Annual Aggregate $250,000 Annual Aggregate $500,000 Annual Aggregate
Please select the limit required for privacy breach notification costs. Please note this cover includes breach notification, legal advice about the notification, voluntary notification, credit monitoring and investigation costs. It is an optional aspect of cover.
Media Liability Limit* Not Required Yes Please
Please select the limit required for the media liability insuring clauses. Please note this cover includes intellectual property rights infringement and defamation. It is an optional aspect of cover.
System Damage & Interruption Limit* Not Required Yes Please
Please select the limit required for the system damage and business interruption insuring clauses. Please note this cover includes costs and expenses for repairing systems in the event of various cyber perils and also loss of revenue cover. It is an optional aspect of cover.
Cyber Crime Limit* Not Required $50,000 Annual Aggregate $100,000 Annual Aggregate $250,000 Annual Aggregate
Please select the limit required for cyber crime. Please note this cover includes third party electronic crime including wire fraud, threats and extortion, telephone hacking and phishing scams.
Deductible* $2,500 $5,000 $10,000
Please select the desired level of self-insured retention for the policy.
Policy Inception Date*
Please enter the date you require the policy to start from. Please note that you cannot bind more than 30 days ahead and no back-dating is allowed.
Policy Period* 12 Month
Is there more than one named insured? If yes, please provide the full name(s) and include a description of the operation and website address below.
Statement of Fact
Do you comply with all the requirements detailed within the Statement of Fact below? Please note that failure to comply with any of these requirements could result in your claim being repudiated by the insurers. *
After full inquiry you are not aware of any circumstances, complaints, claims, loss or penalties/fines levied against you in the last five years, in relation to the risks that this application relates to.
You have anti-virus software installed and enabled on all desktops, laptops and servers (excluding database servers) and it is updated on a regular basis. You also have firewalls installed on all external gateways. You take regular back-ups (at least weekly) of all critical data and store the same offsite or in a fire-proof safe or your outsourced service provider meets this requirement.
You are not aware of any circumstances or complaints against you in relation to data protection or security, or any actual security violations or security breaches either currently or in the past five years.
If you process or store credit card information (where this is not outsourced to a third party that accepts full responsibility for PCI compliance), you have been certified as being PCI compliant within the last 12 months or have successfully completed a self assessment audit.