Insurance Coverage Application

Insurance Coverage Application

Complete this form to apply for CYBER LIABILITY insurance coverage. Your information will be used for underwriting purposes.
GHARRP Member
Housing Authority
Member Housing Authority Representative

First NameLast Name
Position / Title
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Standard Terms

Cyber Liability Coverage Limit
$1,000,000

Cyber Theft Coverage Limit
$250,000

Deductible
$2,500
Do you currently have or have you previously held Cyber insurance coverage?
Prior Insurance Company Name (if applicable)
Prior Insurance Coverage Period
Have you made any cyber-related insurance claims in the past 3 years?
If yes, please provide details of each claim (date, type of claim, amount, outcome)
How many Full Time Employees? (approximate)
How many Part Time Employees?
Annual Revenue - Housing Authority:
Annual Revenue - Wholly Owned Non-Profit Entities:
Authorities with revenues > $10M require additional control measures before coverage can be bound.
If Combined Annual Revenues > $10,000,001, are these controls in place?
What operating system do your authority use?

Other
Other (Operating system, e-mail system, operations management (Yardi)
Signature
Should be Empty: