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Name
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Please complete this form so we can learn more about your cyber law, insurance and incident response needs!
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How many staff are regularly part of your business (include temporary and part-time staff)?
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1 to 30
31 to 50
51 to 250
251 to 500
Over 501
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What was last year's total business revenue?
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Less than $3 million
$3 million to $8.9 million
$9 million to $39.9 million
$40 million to $99.9 million
More than $100 million
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How many workplace sites does your business operate? (Only count business offices, not employees working from home.)
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2 or fewer
3 to 7
8 to 14
15 to 25
Over 25
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What is the average number of customer or partner electronic financial transactions, including credit cards, accepted or sent in a day?
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None
Up to 100
Between 101 and 500
Between 501 and 4999
More than 5000
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In how many states and territories does your business have customers or employees?
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Only 1
2 to 10
11 to 35
36 or more
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Would your business answer "Yes" to any of the following questions: Are you doing business with customers or suppliers or partners outside of the US or Mexico? Do you have staff outside of the US or Mexico? Do you have business in the European Union?
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Yes
No
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Has your business ever entered into a Business Associate Agreement with a Covered Entity under HIPAA/HITECH, or is your business a Covered Entity under HIPAA/HITECH?
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Yes
No
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Is your business considered to be any of the following? - Bank or Credit Union - Financial Advisor - Wealth Management Firm - Mutual Fund or Trust - Insurance Company - Accounting Firm - Commercial Lender - Investor - Pawn Broker - Auto Dealership
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Yes
No
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Does your business engage in any of the following? Sell products or services online (i.e. eCommerce) - Accept payments by credit card, bank transfer, or third-party payment vendor.
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Yes
No
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Does your company offer any of the following services to customers? Managed IT services - Website Hosting - Software as a Service (SaaS) - Network/IT security services.
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Yes
No
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