| Programs

Tech E&O/Cyber/Media Liability

Ascent Underwriting
  • CyberPro Application Form

    As used throughout the application, "you" means the person signing the application, as well as the entity seeking insurance and the applicant's principals, partners, directors, risk managers, or employees that are in a supervisory role. The questions contained in this application pertain to all persons or entities seeking insurance, and not just the signatory. Before any question is answered, please carefully read the declaration at the end of the application form, which are you required to sign. Underwriters will rely on the statements that you make on this form. In this context, ANY INSURANCE COVERAGE THAT MAY BE ISSUED UPON THIS FORM WILL BE VOID IF THE FORM CONTAINS FALSEHOODS, MISREPRESENTATIONS OR OMISSIONS. PLEASE TAKE CARE IN FILLING OUT THIS FORM.

  • 1. General Information

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  • 2. Technology Services Errors & Omissions

    If NO, please skip to section 4.

  • 3. Miscellaneous Professional Services Errors & Omissions

    Please only complete this section if applying for Errors and Omissions coverage. Otherwise go straight to Section 4.

  • 4. Security and Privacy

  • 5. Multimedia

  • 6. Claims and Expiring Information

  • A) Sustained any unscheduled network outages, intrusion, corruption or loss of data?

    B) Received notice or become aware of any privacy violations or been subject to any disciplinary, regulatory actions, sanctions or penalties?

    C) Been involved in a lawsuit, claim or settled any allegations of a suit?

    D) Become aware of any circumstances or incident that could be reasonably anticipated to give rise to a claim against the type of insurance being requested in this application?

  • Data Protection

  • By accepting this insurance you consent to Ascent Underwriting using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example health information or criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities.

    Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and in compliance with relevant Data Protection legislation. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.

  • IMPORTANT - CyberPro Policy Statement of Fact

  • By accepting this insurance you confirm that the facts contained in the proposal form are true. These statements, and all information you or anyone on your behalf provided before we agree to insure you, are incorporated into and form the basis of your policy. If anything in these statements is not correct, we will be entitled to treat this insurance as if it had never existed. You should keep this Statement of Fact and a copy of the completed proposal form for your records.

    This application must be signed by the applicant. Signing this form does not bind the company to complete the insurance. With reference to risks being applied for in the United States, please note that in certain states, any person who knowingly and with intent to defraud any insurance company or other person submits an application for insurance containing false information, or conceals the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

    The undersigned is an authorized principal, partner, director, risk manager, or employee of the applicant and certifies that reasonable inquiry has been made to obtain the answers herein which are true, correct, and complete to the best of his/her knowledge and belief. Such reasonable inquiry includes all necessary inquiries to fellow principals, partners, directors, risk manager, or employees to enable you to answer the questions accurately.
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Quadrant Insurance Managers HQ
501 West Schrock Road Ste. 301
Westerville, OH 43081

Tel: 614.841.1425
Fax: 614.841.1426

Testimonials & Quotes
"We have all heard that hard work is one of the secrets of success. Well, taking the time to understand a buyer’s perspective is just as important. It is something all business people ought to seek."

– Mark D. Harris, CIC
President & CEO, Quadrant Insurance Managers, Inc.
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