SCDOI Connect Login
South Carolina Department of Insurance
Street Address: 1201 Main Street, Suite 1000, Columbia, S.C. 29201
Mailing Address: P.O. Box 100105, Columbia, S.C. 29202-3105
Telephone: (803) 737-6160 or (800) 768-3467
Fax: (803) 737-6231 | Email:
Under the South Carolina Insurance Data Security Act, licensees are required to report Cybersecurity Events to the S.C. Department of Insurance in accordance with the requirements of Section 38-99-40.
Section 1. Information of Entity Experiencing Cybersecurity Event
Licensee Type
Please include either of the following license/entity identification numbers.
Address 1
Address 2
City, State, Zip
Email Address
Section 2. Event Dates
Estimated Occurrence Estimated End Date Discovered
If you did not notify the SCDOI within 72 hours of the Cybersecurity Event, describe the circumstances surrounding the delay in filing your initial event or incident report (attach supporting documentation as needed):
Section 3. Event Type (Check all that apply)
Section 4. Circumstances Surrounding the Cybersecurity Event
How was the information exposed, lost, stolen, or accessed? Include the identity of the source of the Cybersecurity Event, if known.
How was the Cybersecurity Event discovered?
What actions are being taken to recover lost, stolen or improperly accessed information?
Section 5. Third-Party Involvement
Did the Cybersecurity Event occur within the information / systems maintained by the licensed entity or individual reporting the Cybersecurity Event or within the information / systems maintained by a third-party service provider?
Name of the Third-Party Service Provider
Description of the Third-Party Service Provider
What were the specific roles and responsibilities of the Third-Party Service Provider?
Section 6. Information Involved (Check all that apply)
Was the electronic information involved in the Cybersecurity Event protected in some manner?
Please describe the security measures protecting the information
Describe the efforts being undertaken to remediate the situation which permitted the Cybersecurity Event to occur
Section 7. Number of Individuals / Entities Affected
Number affected nationally
Number affected in South Carolina
Section 8. Business-Related Information
If the licensee's own business data was involved, please provide details about the type(s) of data involved
Section 9. Notification Requirements
Is a notice to impacted South Carolina residents / entities required under South Carolina or federal law?
If yes, provide the date of notification: (Note: You should also upload a copy of the notice if not already provided to the SCDOI.)
Section 10. Law Enforcement
Has a police report been filed? Has any regulatory, governmental, or other law enforcement agency been notified? (If yes, please attach documentation of report / notification unless already provided to the SCDOI.)
If yes, provide the date of notification
If yes, provide the date of notification
Section 11. Contact Information of Individual Familiar with Cybersecurity Event and Authorized to Act on Behalf of the Licensee
First Middle Last
Address 1
Address 2
City, State, Zip
Email Address
Section 12. Attachments
Items to Attach:
1. A report of the results of any internal review identifying a lapse in either automated controls or internal procedures, or confirming that all automated controls or internal procedures were followed.
2. A copy of the licensee's privacy policy.
3. A statement outlining the steps the licensee will take to investigate and notify consumers affected by the Cybersecurity Event.
File Document Type Action
Section 13. Attestation
I attest, to the best of my knowledge, that the information submitted on this form is true and correct to the best of my information and belief. By submitting this form, I am acknowledging that I am authorized to submit this form on behalf of the licensee or company. I further understand and agree that Section 38-99-60 of the South Carolina Code of Laws affords confidential treatment to certain information submitted to the SCDOI in accordance with Chapter 99. However, I understand that under state or federal law, the South Carolina Department of Insurance may be required to release statistical or aggregate information provided in this cybersecurity event notification. I acknowledge that copies of consumer notices may also be made available via the Department's website and the Department may also make available summary information related to cybersecurity events requiring public notification such as the identity of the licensee or third-party service provider, the number of individuals affected, the actions taken by the licensee to remedy the cybersecurity event and services available to consumers. I understand that Section 38-99-60 also gives the Director the authority to use the documents, materials or other information furnished by a licensee or someone acting on the licensee's behalf in furtherance of regulatory or legal actions brought as a part of the director's duties.