Cover · free template

Cyber Insurance Intake Form

Collect business details, data exposure, security controls, and incident history so your broker can route a cyber insurance request without extra emails.

A ready-to-use insurance form for small teams who need a reliable intake process: 14 questions, 3 pages, 3 conditional rules.

Questions
14
Pages
3
Layouts
classic · card
Time to complete
≈ 10 min
Conditional rules
3
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Live preview and test console

This is the real form. Answer it to test the 3 conditional rules — nothing is sent or stored.

Page 1 of 3 — Business And Contact

Start Your Cyber Insurance Inquiry

Use the entity seeking coverage, not just its trading name.

Choose the activity responsible for the largest share of revenue.

Enter total revenue for the most recently completed financial year, rounded to the nearest thousand. Use zero if pre-revenue.

Every question on this page is currently visible.

Compliance checklist

Ready to publish
  • Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
  • Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
  • Financial disclaimer present — passingThis form does not provide financial, tax or legal advice. Any figures shown are indicative only and are not an offer of credit or a guarantee of terms. Please seek advice from a regulated adviser before making a decision.
  • Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.

What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.

Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.

Who this template is for

Cyber Insurance Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.

  • Small teams who need a reliable intake process working in insurance.
  • Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
  • Anyone replacing chasing missing details over email with one structured record per enquiry.
  • Respondents are the people you send it to — the form asks them 14 questions across 3 screens.
  • Mobile-heavy audiences, thanks to the one-question-per-screen card layout.

Why this form is useful

It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.

  • 11 questions are required, so submissions arrive complete instead of needing a follow-up email.
  • It collects a verified email address so replies and confirmations land.
  • It pins the request to a specific date.
  • It captures a numeric value you can filter and sort on.
  • Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
  • Splitting the form across 3 pages keeps each screen short and shows respondents how much is left.
  • Every response is stored, searchable and exportable, so nothing depends on one person's inbox.

How to use this template

From copy to live form is a few minutes of work, and every step is reversible.

  1. 1Press “Use this template” — a fresh copy of Cyber Insurance Intake Form lands in your workspace, ready to edit.
  2. 2Rename or delete any question, and change what is required. Nothing here is fixed.
  3. 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
  4. 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
  5. 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.

Logic and conditions blueprint

Exactly how this form behaves as it is answered — 3 conditional rules ship with it.

  • Features advanced show logic: if “Multifactor authentication coverage” is Not fully implemented, the form dynamically exposes “Multifactor authentication gaps”. Otherwise that question never appears.
  • Features advanced show logic: if “Cyber incidents in the past three years” is Yes, the form dynamically exposes “Incident summary”. Otherwise that question never appears.
  • Features advanced show logic: if “Current cyber insurance” is Yes, the form dynamically exposes “Current policy expiration date”. Otherwise that question never appears.
  • All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.

About this template

Use this intake before sending a carrier-specific application. It gives your broker a starting point: who the business is, how much sensitive data it handles, which basic controls are in place, and whether an incident needs follow-up. It is not a quote, a coverage confirmation, or a substitute for underwriting questions. Ask the business owner to complete the company details and have an IT lead verify the security answers. Define one currency for annual revenue before publishing. For sensitive records, request an approximate count of individuals, not a database export. Keep “Not sure” available: an honest unknown is more useful than an unsupported yes. The multifactor authentication question covers email, remote access, and administrator accounts. Treat a gap in any listed area as incomplete implementation. The backup question asks about restore testing as well as separation from production systems; having copies alone does not answer it. Route incident disclosures to a restricted review queue. Do not collect credentials, vulnerability reports, affected-person lists, or forensic files here. After submission, confirm the review owner and use a separately approved channel for any supporting material.

What this form asks

Every question is editable — rename it, make it optional, or delete it entirely.

Page 1 — Business And Contact

  • Legal business namerequired
  • Primary contact namerequired
  • Work emailrequired
  • Primary business activityrequired
  • Annual revenue in USDrequired

Page 2 — Data And Security Controls

  • Individuals with sensitive recordsrequired
  • Multifactor authentication coveragerequired
  • Multifactor authentication gaps
  • Separated backups and restore testingrequired

Page 3 — Incident History And Timing

  • Cyber incidents in the past three yearsrequired
  • Incident summary
  • Current cyber insurancerequired
  • Current policy expiration date
  • Requested coverage start daterequired

14 questions in total.

Example: A Small Distributor Preparing For Renewal

The fictional Lantern Quay Supply LLC submits an intake after its operations manager checks the control answers with IT.

Legal business name
Lantern Quay Supply LLC
Annual revenue in USD
2400000
Individuals with sensitive records
1,001–10,000
Multifactor authentication coverage
Not fully implemented
Multifactor authentication gaps
Email and remote access are covered; MFA for two administrator access types is still being deployed.
Current cyber insurance
Yes
Current policy expiration date
2027-03-01

How the form changes as it's filled in

This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.

Driven by “Multifactor authentication coverage”

  • Reveals questions

    If “Multifactor authentication coverage” is Not fully implemented, the form reveals “Multifactor authentication gaps”.

Driven by “Cyber incidents in the past three years”

  • Reveals questions

    If “Cyber incidents in the past three years” is Yes, the form reveals “Incident summary”.

Driven by “Current cyber insurance”

  • Reveals questions

    If “Current cyber insurance” is Yes, the form reveals “Current policy expiration date”.

Set it up step by step

  1. 1

    Set the revenue currency before launch

    The template uses USD. If your intake serves another market, change the field label and help text together, then use that same currency in your downstream records.

  2. 2

    Have IT verify control answers

    Send the MFA and backup definitions to the person responsible for those systems. Keep unknown answers intact until verified; do not turn planned controls into implemented controls.

  3. 3

    Test all three follow-up paths

    Preview incomplete MFA, a disclosed incident, and existing cyber insurance. Confirm that each reveals its matching follow-up field and that hidden answers are not carried into a new submission.

  4. 4

    Restrict incident review

    Give incident summaries only to staff handling the inquiry. Keep full submission contents out of email notifications, and establish a separate secure process for requested evidence.

Mistakes to avoid

  • Answering that MFA is fully implemented because email is protected while remote access or administrator accounts are not.
  • Counting database rows instead of estimating unique individuals with sensitive records.
  • Treating a requested start date or intake acknowledgment as confirmation of insurance coverage.

What it pairs with

Most teams don't run this form on its own. These are the forms and systems it sits next to.

What to do with the responses

Assign a review owner to confirm unknown answers, clarify disclosed incidents, and identify any carrier-specific follow-up. Send a receipt stating that the inquiry is under review and no coverage has been confirmed.

Works in both layouts

Browse classic templatesBrowse card templates

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Frequently asked questions

Is this a complete cyber insurance application?

No. It is a first-pass intake for routing and preparation. A carrier may require additional questions, evidence, and its own application before making an underwriting decision.

What if we do not know whether a control is implemented?

Select “Not sure” and ask your IT lead or service provider to verify it. Do not answer yes based only on a rollout plan or a tool subscription.

Can we use this to report an active cyber incident?

No. This form is not an emergency response or claims-reporting channel. Follow your organization's incident process and any reporting instructions in your existing policy.

Which form should we use for other business coverage?

Use Business Insurance Quote for a broader business coverage inquiry. Use this intake when cyber exposure and security controls need their own focused review.

Is the Cyber Insurance Intake Form template free to use?

Yes. You can preview and test Cyber Insurance Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.

What does the Cyber Insurance Intake Form template ask for?

It asks 14 questions across 3 pages, 11 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.

Can I edit the Cyber Insurance Intake Form form after copying it?

Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.

How does the conditional logic in this insurance form work?

3 conditional rules ship with the template: Features advanced show logic: if “Multifactor authentication coverage” is Not fully implemented, the form dynamically exposes “Multifactor authentication gaps”. Otherwise that question never appears. Features advanced show logic: if “Cyber incidents in the past three years” is Yes, the form dynamically exposes “Incident summary”. Otherwise that question never appears. Features advanced show logic: if “Current cyber insurance” is Yes, the form dynamically exposes “Current policy expiration date”. Otherwise that question never appears. All rules are editable in the Logic tab.

Where do responses to the Cyber Insurance Intake Form form go?

Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.

Can I embed the Cyber Insurance Intake Form form on my own website?

Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.

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