PROdataInsurance
8407 Normandy Drive
Mount Laurel, NJ 08054
Phone: 877-426-0888
Fax: 877-202-1882
Email: quotes@prodatainsurance.com

Data Breach and Cyber Liability Quote Application

Data Breach and Cyber Liability provides coverage for data breach liability, data breach expense, website liability and identity theft expense.

1. Name of Applicant *			State *	NJ PA DE MD NC SC GA FL AL
2. Nature of Business
3. Web Address
4. Email Address *
5. Phone *
6. Fax
7. Number of Employees
	a. Full time, including independent contractors & leased
	b. Part time, including temporary & seasonal
8. Annual receipts for most recent 12-month period:
9. Does the applicant, or a third party service provider on behalf of the applicant, store non-employee personal information? Yes No
	a. If "Yes", # of records:
	b. If "Yes", do over 10% of these records contain medical or financial account information? Yes No

Coverage cannot be bound using this form. Premium, limits of liability, terms, conditions and eligibility for coverage may change based on any additional information provided in a full submission for any individual risk_ Binding of any quote is subject to underwriter receipt, review and acceptance of completed, siped and dated USLI applications for these products and any other required subjectivities.