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    • Value Based Risk Matrix Intake Form

    • State where your organization's principal affairs of business are maintained.
    • Financial Information

    • Last Complete
      Financial Year

    • Current Year
      (Estimate)

    • Next Year
      (Estimate)

    • Gross Annual Revenue

    • Last Complete Financial Year
    • Current Year (Estimate)
    • Next Year (Estimate)
    • Annual Net Income before Taxes

    • Last Complete Financial Year
    • Current Year (Estimate)
    • Next Year (Estimate)
    • Percentage of Gross Annual Revenue - Payment Card

    • Please enter a number from 0 to 100.
      Last Complete Financial Year
    • Please enter a number from 0 to 100.
      Current Year (Estimate)
    • Please enter a number from 0 to 100.
      Next Year (Estimate)
    • Percentage of Gross Annual Revenue – Online

    • Please enter a number from 0 to 100.
      Last Complete Financial Year
    • Current Year (Estimate)
    • Next Year (Estimate)
    • IT Infrastructure and Asset Replacement Value

    • Last Complete Financial Year
    • Current Year (Estimate)
    • Next Year (Estimate)
    • Losses due to cyber extortion, terrorism, defense, fines, and business interruption

    • Last Complete Financial Year
    • Current Year (Estimate)
    • Next Year (Estimate)
    • Experience

    • 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?

    • 27. During the last three years has the company suffered any unscheduled network outages lasting more than 6 hours?

    • 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?

    • 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?

    • 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 Information

    • 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.