Personal Cyber Insurance e-form

Lionel Isaacs Insurance Brokers (Pty) Ltd ("LIIB") is offering the iTOO [MY]CYlution Cyber Personal lines benefit. The details are fully displayed in the playbook provided and your dedicated underwriter is also available to discuss these benefits with you.

Download iTOO [MY]Cylution Playbook

The form needs to be completed before this benefit can be placed on cover.

LIIB will treat your personal information with caution and have put reasonable security measures in place to protect it. By submitting this form, you agree to the processing and sharing of your personal information. Please refer to our Privacy Policy available on www.liib.co.za.

CLIENT DETAILS

Please fill out the below mentioned client details to ensure appropriate personal information is obtained for risk purposes.

Full_Name*

1. Full name of policy holder

ID_Passport*

2. Identity / Passport number of policy holder

Physical_Address*

3. Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

4. Contact number*

Email*

5. Email address *

	Mega	Giga	Tera	Peta	Exa
Theft of Funds	25,000	50,000	100,000	150,000	250,000
Identity Theft		20,000	50,000	50,000	50,000
Data restoration / malware decontamination*		20,000	25,000	25,000	25,000
Cyberbullying and Cyber Stalking		20,000	25,000	25,000	50,000
Cyber Extortion		5,000	5,000	10,000	25,000
Online Sales and Shopping			1,000	2,500	5,000
Express Kidnapping*				50,000	100,000
Network Security + Privacy Breach and Data Breach Liability					100,000
Privacy Breach and Data Breach by Third Party					10,000
	Monthly premiums
Individual	R22.50	R75.00	R120.00	R175.00	R300.00
Including Partner or 3 children	R25.00	R85.00	R140.00	R195.00	R325.00
Including Partner and 3 children	R27.50	R95.00	R160.00	R215.00	R350.00
Child: a biological child, stepchild, grandchild, legally fostered child or adopted child who must be under the age of 18. Partner: the Insured's spouse, civil union or life partner who the Insured has lived with for longer than 12 months. A maximum of one Partner will be covered under this Policy.

SHARING OF INSURANCE INFORMATION

Your authorisation to Lionel Isaacs Insurance Brokers (Pty) Ltd as well as mandated insurance companies:

I acknowledge that the sharing of information for underwriting and claims purposes is in the public interest, as it will enable insurers to underwrite policies and assess risks fairly and to reduce the incidence of fraudulent claims with a view to limiting premiums.
On my behalf and on behalf of any person I represent herein, I hereby waive my right to privacy with regard to any underwriting and claims information in respect of any insurance policy or claim made or lodged by me, or on my behalf.
I consent to such information being stored in the shared database and used as set out above
I also consent to such information being disclosed to any Insurer or its agent.
I further consent to any underwriting information being verified against legally recognised sources or databases.

DISCLOSURE NOTICE

LIIB is a registered Financial Services Provider (FSP #13343) as a short-term insurance broker.

LIIB earns a binder fee of 3.5% on the premium as well as commission of 20% for every iTOO [MY]CYlution Cyber Insurance policy placed on risk by way of a binder agreement entered into with The Hollard Insurance Company.

LIIB levies an operations fee for risk and claims advice and service, as more fully set out in our comprehensive Guide to Financial Services (a copy of which is available on request). This operations fee also includes a recovery for certain costs related to acting as your independent intermediary, including training, information technology expenditure, audit costs and compliance expenditure. The relevant operations fee is fully disclosed in the policy documentation and/or schedule.

DECLARATION

I hereby warrant that the details contained in the above particulars and statements are true and contain all information known to me affecting the risks insured and that this and any other statement made by me or on my behalf for the purpose of the proposed insurance shall be the basis of and incorporated in the contract between me and the insurer.

In order to provide you with insurance, we have to process your personal information. We will share your personal information with other insurers, industry bodies, credit agencies and service providers. This includes information about your insurance, claims and premium payments. We do this to provide insurance services, prevent fraud, assess claims and conduct surveys. We will treat your personal information with caution and have put reasonable security measures in place to protect it. By submitting this form, you agree to the processing and sharing of your personal information. Please refer to our Privacy Policy available at www.liib.co.za.

It is important that you should disclose all material facts, that is, those facts that would influence an insurer in the acceptance or assessment of your proposal. Failure to disclose such facts may result in claims not being met. If you are in any doubt about whether a fact is material you should disclose it. You should keep a record (including copies of letters) of all information supplied to us for the purpose of entering into this contract.

iToo – Personal Cyber Form

Personal Cyber Insurance e-form

CLIENT DETAILS

SHARING OF INSURANCE INFORMATION

DISCLOSURE NOTICE

DECLARATION

CONFIRMATION OF CONSENT

Products & Services

Company

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