Data Security Act - Notification of Cybersecurity Event

An Official Pennsylvania Government Website

Department of Insurance

Section 1

Contact Information for Licensee Experiencing Cybersecurity Event

Entity/Individual Name

*

NAIC #

*

NAIC Group #

*

Contact Name

*

Contact Business Name

*

Contact Job Title

*

Address 1

*

Address 2

*

Suite/Apt./Building

*

City

*

State

Zip

*

Contact Phone

*

Contact Email

**

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