Insured Name:

Full Address:

Email Address:

Telephone No:

Website address
(if applicable)

ABN No:
Put "TBA" if not known

Business Details

Please provide a description your business activities:

Do you use anti-virus protection software?
Yes    No

Do you provide cloud services or web hosting services?
Yes    No

Are all mobile devices (such as laptops, tablets, smart phones and memory sticks) password protected?
Yes    No

Do you outsource any part of your network, including storage?
Yes    No

Are you aware of any matter that is reasonably likely to give rise to any loss or claim under such insurance, or have you suffered any loss or any claim including but not limited to a regulatory, governmental or administrative action brought against you, or any investigation or information request concerning any handling of personally identifiable information?
Yes    No

Declaration

By submitting this Declaration, the Applicant acknowledges:

• they are authorised by each of the other Applicants to make this Declaration,
• the contents of the Declaration are true and complete,
• they are under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,

Name of person making this declaration: