Cyber Insurance Claim Form

Submit your claim

Page: Claims - Cyber

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Please fill in the details below as accurately as possible to help us progress with your claim.

Insured name*

Policy number*

Email*

Phone*

Third party details (if applicable)

Business Name (optional)

Phone (optional)

Address (optional)

Insurance Product*

Please advise their involvment in this event (optional)

Incident details

Have you been notified by Law Enforcement or your Bank about a potential data breach? (YES / NO If Yes, provide details.)*

Are you being requested to perform a Payment of Card Industry (PCI) Forensic Investigation? (YES / NO If Yes, provide details.)*

Do you believe sensitive data has been compromised and that you need to confirm/deny that a data breach has taken place? (YES / NO If Yes, provide details) (optional)*

Have you received a written demand or notice of claim from a third party seeking compensation or other legal remedy? (YES / NO If Yes, provide details)*

Please explain the circumstances of the Cyber Event*

Insurance history

Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)*

Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)*

Additional information (optional)

Do you have a supporting quote, invoices or photo’s that will assist us to lodge your claim with your insurer? (If yes – please email these to claims@bruce.com.au).