{"id":1991,"title":"PROPOSAL FORM CYBER LIABILITY INSURANCE","purpose":"proposal","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/3-cyber-liability-lnsurance8c0007ff45fd68ff8a0df0055fa61354.pdf","sha256":"cc3c9da99ac0957f33e11bd596590fcfe237b42473778ad41bbef0672ae75d13","pages":5,"collected":"2026-10-20","instructions":{"about":"This form is a proposal for Cyber Liability Insurance to be filled by the policyholder or proposer seeking insurance coverage.","notes":["Answer all questions completely and accurately; mention 'NA' if not applicable","Insurance is a contract of Utmost Good Faith; disclose all material facts","Insurance is not effective until proposal is accepted and premium received","Attach additional sheets if more space is needed","Use the advice of insurance advisor or agent if unclear about terms","Statutory warning on prohibition of rebates under Section 41 of Insurance Act 1938"],"title":"PROPOSAL FORM CYBER LIABILITY INSURANCE","submit":{"to":"ICICI Lombard General Insurance Company Limited","how":"","address":"601 / 602, 6th Floor, Interface Building No. 16, New Link Road, Malad (West), Mumbai - 400 064."},"purpose":"proposal","sections":[{"title":"Client Information","fields":[{"help":"","type":"text","label":"Name of the proposer","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Name of the policyholder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-Mail Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Website","options":[],"required":false,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Fax Number","options":[],"required":false,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Contact Person","options":[],"required":null,"pdf_field":""},{"help":"Enter the amount of liability limit proposed","type":"amount","label":"Proposed Limit of Liability","options":[],"required":null,"pdf_field":""},{"help":"Specify the duration of the proposed policy","type":"text","label":"Proposed Policy Period","options":[],"required":null,"pdf_field":""},{"help":"Provide details if any existing cyber insurance policies are held","type":"text","label":"Details of any existing Cyber insurance covers","options":[],"required":false,"pdf_field":""},{"help":"Limit of liability under existing policy","type":"amount","label":"Limit of Liability","options":[],"required":false,"pdf_field":""},{"help":"Policy period of existing insurance","type":"text","label":"Policy Period","options":[],"required":false,"pdf_field":""},{"help":"Name of existing insurer","type":"text","label":"Insurer","options":[],"required":false,"pdf_field":""},{"help":"Address of existing insurer","type":"text","label":"Address","options":[],"required":false,"pdf_field":""},{"help":"Describe relationship and position if applicable","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"Computer Systems Protection","fields":[{"help":"","type":"yes-no","label":"Does the Company have an information security and privacy policy in place?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Frequency of policy review","type":"text","label":"If ‘Yes’, how often is this policy reviewed?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company provide training for every employee on information security and privacy policy?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are all security threats and incidents logged and investigated?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Company’s disaster recovery program formalized and tested?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is the Company’s business continuity plan formalized and tested?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have antivirus software on all computer systems which are updated in accordance with the software providers’ recommendations?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have firewalls and intrusion monitoring detection in force to prevent unauthorized access?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are all employees assigned specified rights, privileges and unique user ID and passwords, which are changed periodically?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company terminate all associated computer system access and user accounts as part of the regular exit process when an employee leaves the company?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Are connections from laptop, mobile devices, and remote users into the Company’s system secured?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is all valuable and / or sensitive data backed-up by the Company every day?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Describe exceptions if data is not backed up daily","type":"text","label":"If ‘No’, please describe exceptions:","options":[],"required":false,"pdf_field":""},{"help":"Duration backup tapes are stored","type":"text","label":"How long are back-up tapes stored before being overwritten?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have and enforce policies concerning when internal and external communication should be encrypted?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Is personally identifiable information stored on laptop computers and portable media (flash drives, back-up tapes) protected by encryption?","options":["Y","N"],"required":null,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"Professional Services","fields":[{"help":"Year the company was established","type":"number","label":"Year Established","options":[],"required":null,"pdf_field":""},{"help":"Number of subsidiaries","type":"number","label":"No.","options":[],"required":null,"pdf_field":""},{"help":"Total employees in the company","type":"number","label":"Total Number of Employees","options":[],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Have the Company’s activities changed in the past 3 years or do you anticipate any major changes in these activities in the forthcoming twelve months","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Details of changes in company activities","type":"text","label":"If ‘Yes’ please provide full details","options":[],"required":false,"pdf_field":""},{"help":"Columns: Last Completed Year, Current Year Estimate, Forthcoming Year Estimate; Rows: India, Europe, USA / Canada, Rest of the World, Total","type":"table","label":"Please provide the Company’s consolidated fee income by geographical segments","options":[],"required":null,"pdf_field":""},{"help":"Describe professional services offered","type":"text","label":"Please provide in detail the Professional services of the Policyholder","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"Business Interruption","fields":[{"help":"","type":"choice","label":"How fast is the Company likely to incur a loss of profit as a result of an IT network compromise and a total system downtime?","options":["Immediately","1 to 12 Hours","12 to 24 Hours","24 to 48 hours","Greater than 48 hours"],"required":null,"pdf_field":""},{"help":"Estimate daily loss of profit","type":"amount","label":"In case of a non-scheduled closure of the Company’s IT Networks, Please estimate the daily loss of profit for the Company","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"US Exposure","fields":[{"help":"","type":"yes-no","label":"Is the Company subject to any of the following? HIPAA privacy and security rules?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"PCI security standards?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"The Gram, Leach, Biley Act?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Red Flag Rules?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Safe Harbor Program between the United States of America and the European Union?","options":["Y","N"],"required":null,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"Media","fields":[{"help":"","type":"yes-no","label":"Does the Company have a designated officer who has responsibility for monitoring the content of the website from a legal perspective?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have a formal procedure for editing or removing controversial, offensive or infringing material?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Details of procedure for editing/removing material","type":"text","label":"If 'Yes', please provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company offer chat-room or user group discussion facilities through its website?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have a review process in place to screen material displayed on its website for copyright/trademark infringement and slander/libel?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company display material created by third parties (e.g. videos, music, and blogs)?","options":["Y","N"],"required":null,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"Privacy Exposures","fields":[{"help":"","type":"yes-no","label":"Does the Company collect, maintain or process personal information of clients as part of its professional services?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Select all that apply","type":"checkbox","label":"If ‘Yes’, please indicate the type of information which is collected and stored?","options":["Social Security Numbers","Personal Health Data","Credit Card Information","Bank Account Information","Employee Information","Other (Please Describe)"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company have a designated privacy officer who has responsibility for meeting the Company’s worldwide obligation under privacy and data protection laws?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Name or designation of responsible person","type":"text","label":"If ‘No’, who is responsible for management of, and compliance with the Company’s privacy policies?","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company share personal information gathered from customers with Consultants or third parties?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"If ‘Yes’, is explicit consent of the customers taken before sharing such information?","options":["Y","N"],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Does the Company conduct regular reviews of the consultant and third party service providers to ensure that they meet the company’s requirement for personal information in their custody?","options":["Y","N"],"required":null,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"Claims Information","fields":[{"help":"","type":"yes-no","label":"Has the Company ever been investigated in respect of the safeguards for personal information?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Details of investigations","type":"text","label":"If ‘Yes’, please provide details:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the Company ever received complaints about how someone’s personal information is mis-handled?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"","type":"yes-no","label":"Has the Company sustained any unscheduled network outage or interruption or denial of service attack in the last thirty-six months?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Details of network outages or attacks","type":"text","label":"If ‘Yes’, please provide details","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is there any existing or pending claim against the Company?","options":["Y","N"],"required":null,"pdf_field":""},{"help":"Provide claim details","type":"text","label":"If ‘Yes’, please provide details for at least the past 5 years: Nature of Claim, Amount of Loss, Current Status, Remedial Measures","options":[],"required":false,"pdf_field":""},{"help":"Settlement details","type":"text","label":"Please provide details of settlement if any, in the past 5 years:","options":[],"required":false,"pdf_field":""},{"help":"","type":"yes-no","label":"Is any person proposed for cover aware of any facts or circumstances which might afford grounds for any future claim(s) that would fall within the scope of the proposed coverage or indicate the probability of any future claim(s)?","options":["YES","NO"],"required":null,"pdf_field":""},{"help":"Details of potential future claims","type":"text","label":"If ‘Yes’, please provide details:","options":[],"required":false,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"Documents Required","fields":[{"help":"Attach the listed documents","type":"attachment","label":"Please provide copies of the following documents to ICICI Lombard General Insurance Company Ltd.","options":[],"required":null,"pdf_field":""}],"filled_by":"proposer / policyholder"},{"title":"Declaration","fields":[{"help":"Location where form is signed","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Signatory's designation","type":"text","label":"Designation","options":[],"required":null,"pdf_field":""},{"help":"Signature and stamp of authorized signatory","type":"signature","label":"Authorized Signatory Signature & Stamp","options":[],"required":true,"pdf_field":""}],"filled_by":"authorized signatory"}],"deadlines":["Inform ICICI Lombard immediately of any change in information before policy issuance","Undertake to inform changes immediately, not later than 30 days"],"applies_to":"Cyber Liability Insurance","attachments":["Expiring Cyber Policy Copy (If it is not ILGIC policy)","Network Security Policy","Business Interruption Policy"],"declarations":["Consent to verify identity/address proof through Central KYC Registry or UIDAI or other modes","Premium paid from legally acquired sources and future premiums will be paid similarly","Answers and documents submitted are true, complete and accurate with no withheld material information","Company may call for documents to establish source of funds","Details furnished are true and correct and changes will be informed within 30 days","False or misleading information may lead to liability"],"dropped_labels":4},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/icici-lombard-general-insurance/1991-proposal-form-cyber-liability-insurance"}