Value Based Risk Matrix Intake FormOrganization Name* State of Domicile* State where your organization's principal affairs of business are maintained. Year Established* Number of Employees* Organization Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Subsidiaries(none)Nature of Business* Website* Industry Sector* Submitter Name* First Last Submitter Job Title* Submitter Email Address* Submitter Work Phone*Submitter Mobile PhoneFinancial InformationLast CompleteFinancial YearCurrent Year(Estimate)Next Year(Estimate)Gross Annual RevenueLast Complete Financial Year*Last Complete Financial YearCurrent Year (Estimate)*Current Year (Estimate)Next Year (Estimate)*Next Year (Estimate)Annual Net Income before TaxesLast Complete Financial Year*Last Complete Financial YearCurrent Year (Estimate)*Current Year (Estimate)Next Year (Estimate)*Next Year (Estimate)Percentage of Gross Annual Revenue - Payment CardLast Complete Financial Year*Please enter a number from 0 to 100.Last Complete Financial YearCurrent Year (Estimate)*Please enter a number from 0 to 100.Current Year (Estimate)Next Year (Estimate)*Please enter a number from 0 to 100.Next Year (Estimate)Percentage of Gross Annual Revenue – OnlineLast Complete Financial Year*Please enter a number from 0 to 100.Last Complete Financial YearCurrent Year (Estimate)*Current Year (Estimate)Next Year (Estimate)*Next Year (Estimate)IT Infrastructure and Asset Replacement ValueLast Complete Financial Year*Last Complete Financial YearCurrent Year (Estimate)*Current Year (Estimate)Next Year (Estimate)*Next Year (Estimate)Losses due to cyber extortion, terrorism, defense, fines, and business interruption Last Complete Financial Year*Last Complete Financial YearCurrent Year (Estimate)*Current Year (Estimate)Next Year (Estimate)*Next Year (Estimate)Experience* Yes No 26. During the last three years has anyone alleged that their personal information was compromised or has the applicant notified customers that their information was or may have been compromised? * Yes No 27. During the last three years has the company suffered any unscheduled network outages lasting more than 6 hours? * Yes No 28. Is the company or any of its partners, directors or officers aware of or are there any circumstances that may give rise or have given rise to a claim under existing insurance policies?* Yes No 29. During the last three years has any person or organization brought a lawsuit or made a claim against you involving copyright infringement, trademark infringement, patent infringement, consumer litigation, a defamation action or a privacy violation?* Yes No 30. During the last three years has anyone alleged or have any claims been made against the applicant in relation to disparagement, copyright infringement or trade mark or trade name infringement? Insurance Policy InformationInsurance Policy Information Shared Folder*(No shared folder information provided yet)About the Shared Folder Information Provide a link to a shared folder that you've set up to hold the insurance policy documents needed for the evaluation review. This could be a Dropbox, Google Drive, OneDrive, SharePoint or any other type of shareable folder. You may include a note or instructions along with the link information. If you need to provide an email address to enable the sharing, use RayBernard@go-rbcs.com. It's okay to use multiple shared file or folder links. If you are emailing a password-protected Zip file with the data files in it, put a note about that here and include the password. If you have questions about this, please contact Ray Bernard at (949) 681-9814 or or RayBernard@go-rbcs.com.HiddenDate MM slash DD slash YYYY