Cyber Insurance Claim Form
Use this form to report a cyber incident and submit a claim with the details, impact, response actions, and supporting documents.
Claimant and Policy Information
Claimant Full Name
*
First Name
Middle Name
Last Name
Organization / Company Name
Role / Title
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Policyholder Name
*
First Name
Middle Name
Last Name
Policy Number
*
Policy Effective Date / Coverage Period
*
-
Month
-
Day
Year
Date
Relationship to Policyholder
Please Select
Owner
Employee
Broker
Agent
Administrator
Other
Cyber Incident Details
Incident Date
*
-
Month
-
Day
Year
Date
Incident Discovery Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Reporting Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Type
*
Phishing
Ransomware
Malware
Business Email Compromise
Unauthorized Access
Data Breach
Fraud / Transfer Diversion
Denial of Service
Lost / Stolen Device
Other
Narrative Description of Incident
*
Is the Incident Ongoing?
*
Yes
No
Affected Systems, Data, and Business Impact
Affected systems, devices, accounts, or applications
*
Servers
Workstations
Laptops
Mobile devices
Cloud services
Email accounts
Business applications
Databases
Network devices
Other
Data impact type
*
Encrypted only
Exfiltrated only
Both encrypted and exfiltrated
Unknown
Categories of data affected
*
Employee data
Customer data
Financial records
Credentials
Intellectual property
Operational data
Unknown
Estimated number of records affected
Estimated number of users affected
Business interruption impact
*
No interruption
Minimal interruption
Moderate interruption
Severe interruption
Complete outage
Summary of operational or financial losses
Response Actions and Notifications
Immediate containment or mitigation steps taken
*
Teams or vendors involved in response
IT Security
IT Operations
Legal
External Incident Response Vendor
Digital Forensics Firm
Managed Service Provider
Cyber Insurance Representative
Other
Have law enforcement or regulators been notified?
*
Law enforcement only
Regulator only
Both
No
Pending
Have affected customers or partners been notified?
*
Yes
No
Pending
Date and time of notifications
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
External support engaged
External Incident Response
Legal Support
Forensics Support
IT Support
Not yet engaged
Supporting Documents and Final Attestation
Incident reports
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Emails or screenshots
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Forensic summaries
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Invoices or remediation estimates
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Other supporting documentation
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Submit Claim
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