Protect the Good Life

Name and address of entity or person that owns or licenses the data subject to the breach

Name Required

Address Required

City/Town/Village Required

State

Zip Code Required

Submitted by Required

Title Required

Dated Required

Firm Name and Address (if different than entity) – please write N/A if not applicable

Phone Required

Email Required

Relationship to Entity Required

Type of Organization

Type

Other (specify) – please write N/A if not applicable

Number of persons affected

Nebraska Residents Required

Total (Nebraska included) Required

Date(s) Breach Occurred Required

Date Breach Discovered Required

Date Consumers Notified Required

Manner of notification to affected persons

Written

Electronic (email)

Telephone

Substitute

Reason for delay, if any, in sending notification – please write N/A if not applicable

Theft of computer, device, or media

Phishing

Loss of computer, device, or media

Other (specify)

Insider wrongdoing

Inadvertent disclosure

External systems breach (i.e. hacking)

Describe the circumstances surrounding the breach Required

Name

Social Security number

Driver's license number

Electronic identification number or routing code

User name or email address, in combination with password or security question

Account Number

Security code, access code, or password that would provide access to financial account

Unique biometric data

Credit or debit card number

State identification card number

Describe the security measures protecting the information Required

Describe any measures taken to prevent a similar security breach from occurring in the future Required

Data Breach Notification

Name and address of entity or person that owns or licenses the data subject to the breach

Type of Organization

Number of persons affected

Dates (mm/dd/yyyy)

Manner of notification to affected persons

Type of breach (select all that apply)

Information acquired (select all that apply)

Security Authentication Required

Nebraska Attorney General