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If you are human, leave this field blank.Business InformationThe form below will give us the info we need to answer your questions about cost and options.Industry and/or Professional Services *Please provide a detailed description of the type of industry your business operates in or the professional services provided. e.g. Residential home construction, family style restaurant, software programming, lawyer, doctor, real estate agent / broker, ect.Number of Employees *How many employees both full and part time does the business employ?Do you use subcontractors? *NoYesEstimated annual sub-contractors costEstimated Annual Sales *Limits<$100,000$100,000$300,000$500,000$1,000,000$2,000,000>$2,000,000Additional Businesss informationHas your business had any cyber/privacy incidents, losses or claims within the last 3 years that where in excess of $5,000? *NoYesAre you aware of any circumstances that could give rise to a claim under this insurance policy? *Let us know if something has happened in your business that you think might become a claim a loss under any cyber coverage you choose to purchase.NoYesDoes your business enable disk encryption on laptops, desktops and other portable media devices? *Many times these are options within the devices when they purchased, sometimes these are separate services/software that has to be added.NoYesDoes your business accept, store, transmit credit cards or collect Personally Identifiable Information (PII) or Protected Health Information (PHI) for its customers? *NoYesHow many payment card numbers (credit cards, debit cards, etc) does your business store, process, transmit or have access to?How many customer records that include PII or PHI does your business have/store?Does your business have procedures to back up, archive, and restore sensitive data and critical business systems? *NoYesDoes your business require dual control (multiple designated people giving their authorization) when transferring funds in excess of $15,000 USD? *NoYesHas your business been subject to any complaints concerning the content of it's website, advertising materials, social media or other publications? *NoYesDoes your business have procedures to remove content, if/when it is found to be libelous, infringing, or otherwise contriversial? *NoYesDo you currently have insurance?YesNoExpirationInsurance Company NameContact InformationYou are almost there. 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(“Dopazo”) to call or text you with offers and reminders at the number you provided, including through the use of the possible use of automated technology and recorded messages. You certify that the number you provided is your own number. If you change your number, you will notify Dopazo as soon as possible. You are not obligated to provide this authorization and it is not a condition to receive a quote or purchase or renew your insurance. You may revoke this authorization at any time by remove@dopazo.com. You understand and agree that standard text messaging rates will apply to any text messages sent to you by Dopazo and that Dopazo will not be responsible for any charges for text messaging.Federal Employer Number FEINWebsiteAcknowledgement *I AgreeI acknowledge and understand that insurance coverage cannot be bound or changed via submission of any online form/application provided on this site or otherwise. No binder, insurance policy, change, addition, and/or deletion to insurance coverage goes into effect unless and until confirmed in writing directly by a licensed agent.Submit