Cyber & Privacy Protection Insurance Proposal...

If you prefer to talk to a broker first, call Liability Brokers 1300-881-779
between 8.15am and 5.15pm E.S.T. business days and receive an indicative quote over the phone.


Insured Name:


Suburb or town:


Email Address:

Telephone No:

Website    www.

 (if applicable)

ABN No:    Put "TBA" if not known


Business Details

Please provide a description your business activities:

Do you use anti-virus protection software?

Yes    No

Are all mobile devices (such as laptops, tablets, smart phones and memory sticks) password protected?

Yes    No

Do you outsource any part of your network, including storage?

Yes    No

Are you aware of any matter that is reasonably likely to give rise to any loss or claim under such insurance, or have you suffered any loss or any claim including but not limited to a regulatory, governmental or administrative action brought against you, or any investigation or information request concerning any handling of personally identifiable information?

Yes    No

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By submitting this Declaration, the Applicant acknowledges:
  • they are authorised by each of the other Applicants to make this Declaration,
  • the contents of the Declaration are true and complete,
  • they are under a continuing obligation to immediately inform QBE of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,
  • they authorise the Insurer to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.

Name of person making this declaration: