Registration Form ~Data & Cyber Protection

Cyber & Data Protection Application Form

Please complete the form below to apply for our Cyber & Data Protection solutions. All information provided will be treated as strictly confidential.

1. Company / Applicant Information

• Full Legal Company Name:
• Trading Name (if different):
• Company Registration Number:
• Year Established:
• Industry / Sector:
• Number of Employees:
• Annual Revenue (USD / ZAR / Other):
• Website URL:
• Physical Address:
• Primary Contact Person:
  • Full Name:
  • Job Title:
  • Email Address:
  • Phone Number:

2. Business Operations

• Describe your main business activities:
• Do you collect, store, or process personal or sensitive data? ☐ Yes ☐ No
  • If Yes, please specify types of data (e.g. customer personal info, health data, financial data, intellectual property):
• Countries where you operate / store data:
• Do you use cloud services or third-party vendors for data storage/processing? ☐ Yes ☐ No
  • If Yes, list main providers (e.g. AWS, Microsoft Azure, Google, Others):

3. Current Cyber Security & Data Protection Measures

• Do you have a Cyber Security Policy in place? ☐ Yes ☐ No
• Do you have Cyber Insurance currently? ☐ Yes ☐ No
  • If Yes, name of current insurer and sum insured:
• Key security measures implemented (select all that apply): ☐ Firewall & Antivirus ☐ Multi-Factor Authentication (MFA) ☐ Employee Security Training ☐ Data Encryption ☐ Regular Backup Systems ☐ Incident Response Plan ☐ Vulnerability Scanning / Penetration Testing ☐ Other (please specify):

4. Risk Profile

• Have you experienced any cyber incidents or data breaches in the last 3 years? ☐ Yes ☐ No
  • If Yes, please provide brief details and outcome:
• Highest value of a single data asset or potential loss exposure (e.g. ransomware demand, data breach fines, business interruption):
• Do you handle high-risk data (e.g. medical, financial, government contracts)? ☐ Yes ☐ No

5. Coverage Requirements

• Type of cover required (select all that apply): ☐ Cyber Breach Response & Notification ☐ Ransomware Recovery ☐ Data Breach Liability ☐ Business Interruption due to Cyber Attack ☐ Third-Party Cyber Liability ☐ Regulatory Fines & Defence Costs ☐ Digital Asset Restoration ☐ Other (please specify):
• Desired Sum Insured / Limit of Indemnity:
• Additional requirements or specific concerns:

6. Declaration & Consent

• I/We confirm that the information provided is true and complete to the best of my/our knowledge.
• I/We consent to the processing of this information for the purpose of providing a Cyber & Data Protection quotation.

e-Signature: