Cybersecurity Incident Coverage Modification Form
Use this form to request changes to an existing cybersecurity incident coverage policy and provide the incident details, affected systems, requested coverage updates, and supporting documents needed for review.
Requester and Policy Information
Full Name
*
First Name
Middle Name
Last Name
Job Title / Role
*
Organization Name
*
Work Email
*
example@example.com
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Policy Number / Coverage Reference
*
Current Policy Effective Date
*
-
Month
-
Day
Year
Date
Preferred Contact Method
*
Please Select
Email
Phone
Other
Incident and Coverage Change Details
Incident name or reference
*
Incident date and time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident type
*
Please Select
Malware
Ransomware
Phishing
Data breach
Unauthorized access
Service outage
Other
Systems or data affected
*
Description of what happened
*
Has the incident been reported?
*
Yes
No
In progress
Requested coverage modification type
*
Please Select
Increase limit
Decrease limit
Add endorsement
Remove endorsement
Change deductible
Extend retroactive coverage
Other
Current coverage setting
*
Requested coverage setting
*
Requested effective date for the change
*
-
Month
-
Day
Year
Date
Risk, Loss, and Supporting Information
Estimated financial impact or loss amount
*
Were any third parties affected?
*
Yes
No
Unsure
Was any data exposed?
*
Yes
No
Unsure
Were law enforcement or regulators notified?
*
Yes
No
Planned
Not required
Has the organization had prior similar incidents or open claims?
*
No
Yes, prior incidents only
Yes, open claims only
Yes, both
Unsure
Brief mitigation actions summary
*
Supporting documents
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Additional notes
Submit Modification Request
Should be Empty: