U1003/557, Little Lonsdale Street, Melbourne
Tel: 03 8640 0962
Email: index@samatex.com

Application Form

Home PageApplication Form

1: Application Name:

2: Contact Name:





3: Business Activity: (Please describe)

4: Total Revenue of the company of the company for the past 12 month:

5: Coverage Required:
(please indicate the level of coverage required by ticking the
option)

$

6: Does Applicant collect, store or process personally identifiable or other
confidential information?

7: What is the total number of records held by Applicant excluding employee
records?

8: Does Applicant have a business continuity plan in place and confirm you
can up and running within:

or Within other: hours/day

9: Does Applicant have an incident response plan for network intrusions and
data security breaches?

10: Does Applicant have a Privacy policy?

11: Does Applicant have a policy of shredding documents when disposing off
confidential?

12: Does Applicant use firewalls to prevent unauthorized access to its
networks and computer systems?

13. Does Applicant have antivirus software installed on its network and PCs?

14. Does Applicant regularly implement a written patch management process?

15. Does Application's business encrypt its critical or sensitive data at
rest?

16. Is the Personal Information (PI) held on portable media devices
encrypted?

17. Does Applicant conduct security awareness training for its employees?

18. Are Applicant passwords secure ( i.e not default passwords and regularly
changed)?

19. Does Applicant process credit or debit card transactions?

20. Please provide the value of the average monthly payment transactions
processed.

21. How frequently does Applicant back up electronic data?

22. Does Applicant use a third | parthy vendor for the following services?
If 'Yes', please provide the name of the thirt party(s).

NetWork Securtiy
Cloud/back-up provider
Internet service provider
Application critical software provider
payment processor
POS hardware provider

23. Has the Applicant's business carried out a risk assessment recently?

24. In the past of 5 years has the business been made aware of any cyber
or data breach event that is reasonably likely to give rise to a loss or
claim under such insurance policy, or have they suffered any loss, or
claim being made against them?

25: STAMP DUTY SPLIT:
For the purpose of calculating Stamp Duty please confirm the number of
employees in the relevant State of Australia

NSW VIC QLD SA WA TAS ACT NT Overseas

Declaration

We declare that the above answers, statements, particulars are true to the best of the knowledge and belief of
the Applicant.

Signed:
Name:
Position:
Date: