Etiqa Insurance Pte. Ltd. (Company Reg. No.
201331905K)
One Raffles Quay #22-01 North Tower Singapore 048583 | T +65 6336 0477 | F +65 6339 2109 | [Link]
_______________________________________________________________________________________
ETIQA SME CYBER INSURANCE PROPOSAL FORM
Notes to Proposer
a. Please answer all questions as fully as possible.
b. If there is insufficient space to complete any of your answers, please continue on your headed paper.
c. If you have a company brochure, please forward it with this proposal.
d. If cover is required for any subsidiary companies, please provide information relating to the subsidiaries by
completing the remainder of the form, including Claims and Incident History.
e. This form must be signed and dated by a Director of the Company.
A. COMPANY INFORMATION
1. Company Name :
2. Principle Address :
3. Corporate Website :
Addresses
4. Subsidiary(ies) to be : Company Name Country
insured
(a)
(b)
(c)
5. Description of the
:
Company’s business
operations, including
that of subsidiaries to
be covered
6. Annual Revenue : Singapore SGD Rest of the world SGD
7. Does the Company have a website that provides e-commerce or online services? YES NO
If YES,
a) what percentage of the online business contributes to the Company’s Annual Revenue? ________ %
b) what is the number of user ID/login registered under the e-commerce site or online
services? ________ users
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Etiqa Insurance Pte. Ltd. (Company Reg. No. 201331905K)
One Raffles Quay #22-01 North Tower Singapore 048583 | T +65 6336 0477 | F +65 6339 2109 | [Link]
_______________________________________________________________________________________
B. INFORMATION SECURITY AND CONTROLS YES NO
8. Does the Company have firewalls in place within its network and anti-virus software installed
on all systems?
9. Does the Company enforce software update process with the installation of software
patches within 30 days of release?
10. Are users required to update passwords regularly?
11. Is 2-factor authentication utilized for all remote access ([Link]) to the internal network?
12. Does the Company have a Disaster Recovery Plan or Business Continuity Plan taking cyber
perils into consideration?
13. Does the Company back up valuable or sensitive data on a daily basis?
If NO, How frequently is the data backed up?
14. Does the Company outsource any information system function(s) or application(s) to third
parties?
(a) Desktop Management
(b) Server Management
(c) Network Management
(d) Network Security Management
(e) Application Management
(f) Use of Cloud Computing Software-as-a-Service
(g) Use of Cloud Computing Platform-as-a-Service
(h) Use of Cloud Computing Infrastructure-as-a-Service
If YES, please provide names of the service providers and indemnification provisions under contract.
C. INSURANCE HISTORY YES NO
15. Does the Company currently have in place cyber insurance?
If YES, please provide details:
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Etiqa Insurance Pte. Ltd. (Company Reg. No. 201331905K)
One Raffles Quay #22-01 North Tower Singapore 048583 | T +65 6336 0477 | F +65 6339 2109 | [Link]
_______________________________________________________________________________________
16. In the past three years, has an insurer declined a proposal, cancelled or not renewed any
similar cyber insurance?
D. CLAIMS AND INCIDENTS HISTORY YES NO
17. In the past three years, has the Company suffered any loss or made any claim or faced
any regulatory investigation brought against the Company, its director(s), officer(s) or
employee(s) with regards to the coverage sought?
If YES, please provide details:
18. In the past 3 years, has the Company sustained any system intrusion, tampering, malware
(including virus) attack, loss of data, loss of portable media, hacking incident, extortion
attempts, data theft or similar?
If YES, please provide details:
19. Does the Company, its directors, officers or employees have knowledge or information of
any fact, circumstances, situation or event which may give rise to a claim under the
proposed Etiqa SME Cyber Insurance?
If YES, please provide details:
E. COVER REQUIRED
20. Please select the Policy Limit required:
SGD100,000 SGD200,000 SGD300,000
SGD400,000 SGD500,000 Above SGD500,000
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Etiqa Insurance Pte. Ltd. (Company Reg. No. 201331905K)
One Raffles Quay #22-01 North Tower Singapore 048583 | T +65 6336 0477 | F +65 6339 2109 | [Link]
_______________________________________________________________________________________
DECLARATION
(a) I/We accept that the completion of this proposal form does not bind the Company or Etiqa Insurance Pte
Ltd (Etiqa) to effect a contract of insurance.
(b) I/We agree that, if an insurance policy is issued, this proposal and any other information supplied prior to
inception of the insurance policy, shall form the basis of the contract of insurance effected hereon and shall
be incorporated therein.
(c) I/We hereby declare that I am authorised to complete this proposal on behalf of the Company, that the above
statements and particulars are true and that full enquiry has been made to ensure their accuracy. I have not
omitted, suppressed or misstated any material facts which may be relevant to underwriters’ consideration
of the proposal.
(d) I/We undertake to inform Etiqa of any material change to any fact contained herein that occurs prior to the
inception of the contract of insurance.
Director’s Name: Title:
Signature: Date:
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