Cyber Insurance Form

For calculating stamp duty, outline the breakdown of revenue (000’s) or employee numbers by state/region:

*Note: To qualify as multi-factor authentication, the authentication mechanism needs to be knowledge (something the user and only the user knows) and possession (something the user and only the user has). That way the compromise of any single device will only compromise a single authentication factor.

Includes cyber theft, telephone phreaking, identity-based theft, push payment theft and cryptojacking. Does not include socially engineered theft unless selected below.

D&O Liability is only available for unlisted companies.

The Tangible Property sublimit forms part of and is not in addition to the limit for Section C - Cyber Event Response Costs.

Note: Subsidiaries of the policyholder are automatically covered and do not require scheduling. Listing an entity here does not extend cover or affect cover in any way. This list is for your convenience only.

If Yes, please list the affiliates and revenue below and tell us how you are affiliated and about the IT. Press the + Button to the right to add additional Affiliates.

Note: Listing an entity here means you are submitting it to Emergence for consideration. Cover will only apply to those entities accepted by Emergence and scheduled on the policy. You must provide revenue estimates for each entity and include revenue from all affiliates for the coming 12 months in your total estimated revenue.

I/we acknowledge that:

1. I/we have read and understood the important information provided on the last page of this document

in the important information section.

2. I/we are authorised by all those seeking insurance to make this proposal, and declare all information

on this proposal and any attachment is true and correct.

3. I/we authorise the underwriter to give to, or obtain from, other insurers or any credit reference service,

any information relating to insurance held by me/us or any claim in relation thereto.

4. I/we acknowledge that, where answers are provided in the proposal are not in my/our handwriting,

I/we have checked and certify that the answers are true and correct.