commercial_crime_fidelity_dishonesty_forgery

Fidelity/Dishonesty Bond Form

Call us at 800-921-1008 with any questions

IMPORTANT INSTRUCTIONS
This Application will only be accepted for Privately held commercial companies and Non-Profit organizations with:
• 250 or fewer employees and $100 million or less in assets and $100 million or less in revenues
This Application will not be accepted for Public Companies, Government Entities or Financial Institutions.

Applicant means all corporations, organizations or other entities, including subsidiaries and Employee Benefit Plans subject to ERISA, that are proposed for this insurance in Item I. APPLICANT INFORMATION.

If completed by a broker, check below.

Broker

Broker Name / Company

Broker Phone Number

Broker Email

Broker Address

State

Check here for Third Party Crime coverage

Third Party Crime

Third-party fidelity bonds protect businesses against intentionally wrongful acts committed by people working for them on a contract basis (e.g., consultants or independent contractors).

I. APPLICANT INFORMATION

1. Name of Applicant

Contact Name

Phone Number

Email

Address

State

Year applicant’s business was established

Description of Applicant’s operations

2. Does the Applicant wish to include additional entities (e.g., affiliates, partnerships, joint ventures) as insureds for coverage?

Yes No

Complete the following table indicating all additional entities for which coverage is requested:

*IMPORTANT NOTE: Receipt of this information does not constitute an agreement that coverage will be provided to the listed entities.

3. Total number of employees** at all locations

4. Total number of volunteers (only if Applicant is a non-profit organization)

5. Total number of locations:

6. a. Number of locations outside the United States:
Indicate domicile of each location on a separate page.

b. Number of employees* domiciled outside the United States:

*Employee count should include full time and part time employees (including leased, seasonal and temporary).

7. Indicate the total amount of specified property INSIDE the premises for all locations combined:

8. Indicate the total amount of specified property being transported by a messenger OUTSIDE the
premises for all locations combined:

**Retail Checks are only those checks that are accepted as immediate payment for retail products or services.

9. Scope of financial statement preparation:

Note: Omit Question 10. if the limit requested is $5,000,000 or greater, and attach the most recent annual financial statement and CPA Management Letter.

10. For your most recent fiscal year end please complete the following financial information:

Fiscal Year End Date:

Current Assets

Revenues

Total Assets

Net Income (Net Loss)

Current Liabilities

Cash Flow from Operations

Long Term Debt

Net Equity/Net Assets (Deficit Equity)

11. During the past 24 months has the Applicant experienced, or during the next 12 months does the Applicant anticipate, any reorganization or arrangement with creditors under federal or state law? If Yes, please attach an explanation with full details of the circumstances of such an event.

anticipate, any reorganization or arrangement with creditors under federal or state law?

Yes No

II. INTERNAL CONTROL INFORMATION

1. Does someone other than the person responsible for reconciling bank accounts:

Make deposits?

Yes No

Make Withdrawals?

Yes No

Sign Checks?

Yes No

2. Is countersignature of checks required?

Yes No

3. Are all incoming checks stamped “for deposit only” immediately upon receipt?

Yes No

4. Is segregation of duties practiced in the following areas:

Inventory management?

Yes No

Cash receipts?

Yes No

Vendor approval?

Yes No

Oversight of blank check stock?

Yes No

Purchase order approval and payment?

Yes No

Retail checks and credit card receipts?

Yes No

5. Is a physical count of inventory conducted at least annually?

Yes No

6. Are inventory records computerized?

Yes No

7. Indicate if you have or perform any of the following during the hiring process:

Prior employment verification

Yes No

Drug testing

Yes No

Education verification

Yes No

Credit history

Yes No

Criminal history

Yes No

8. Is there a software security system in place to detect fraudulent computer usage by employees, agents and outsiders?

Yes No

9. Are passwords and access codes changed at regular intervals and when users are terminated?

Yes No

10. Are EDP systems, programs, and procedures, including changes thereto, authorized, documented and tested?

Yes No

11. Is dual authorization required for all wire transfers?

Yes No N/A

12. Indicate any of the following characteristics or exposures that apply to your business operations:

Precious metals or gemstones

Yes No

Managed assets of others

Yes No

Care, custody & control of client property

Yes No

Warehousing operations

Yes No

High unit, portable inventory

Yes No

None applicable

Yes No

If you checked any of the characteristics or exposures above, please provide details that quantify the exposure and briefly describe the controls in place to protect you from loss in a separate attachment.

III. CURRENT INSURANCE INFORMATION/REQUESTED INSURANCE TERMS

Desired Crime Coverage

Fidelity: Employee Theft

Fidelity: ERISA Fidelity

Fidelity: Employee Theft of Client Property

Forgery or Alteration

On Premises (Money, Securities and Other Property)

In Transit (Money, Securities and Other Property)

Money Orders and Counterfeit Money

Computer Crime + Funds Transfer Fraud

Expiring insurer:

Date coverage first purchased:

Requested effective date:

THIRD PARTY CRIME CONTRACT SPECIFIC COVERAGE
Skip this section if Third Party Crime Blanket Coverage is desired

Name of contracted client

Total number of employees providing services to the client under terms of the contract

Describe the specific services provided to the client under terms of the contract

Are any services performed for contracted clients off the clients’ premises?

Yes No

Are you presently bidding on this contract?

Yes No

Is this contract presently in effect?

Yes No

Contract effective date

Contract expiration date

Annual gross dollar value of the contract:

THIRD PARTY CRIME BLANKET COVERAGE
Skip this section if Third Party Crime Contract Specific Coverage is desired

Total number of employees providing services for contracted clients

Total number of client contracts currently in place

Describe the services provided by your employees while on your contracted clients’ premises

Are any services performed for contracted clients off the clients’ premises?

Yes No

UNDERWRITING INFORMATION

Do you verify the employment background of prospective employees?

Yes No

Do you use non-employees to perform contracted client services?

Yes No

Describe the supervisory procedures for all individuals engaged in performing contracted client services.

Do you assess the services provided by your employees for contracted clients at least annually?

Yes No

List and describe all losses sustained by contracted clients and caused by your dishonest employee during the past 5 years, whether or not you were reimbursed by insurance. Include corrective actions taken.

No Losses

Third Party requested limit

Third Party requested deductible

LOSS INFORMATION

Has the Applicant or any proposed insured sustained any crime-related losses in the past 3 years? If Yes, please write a full explanation of the loss including date, description, status of the loss, amount of the loss and procedures implemented to avoid further losses.

Yes No

Loss Information

REQUIRED ATTACHMENTS

As part of this Application, please submit the following documents: Most recent annual financial statement, and CPA Management Letter, for limit requests of $5,000,000 or greater.
For each additional entity for which coverage is requested please attach a separate page or an organization chart
which includes the name, description of operations, employee count and locations.

Third Party Crime Required Documents:
• (If Blanket Coverage is desired) Specimen copy of the contract used for all clients
• (If Contract Specific Coverage is desired) A copy of the entire contract which requires Third Party Crime Coverage,
specifically the section which details the work to be performed

Important Note: Receipt of this information does not constitute an agreement that coverage will be provided to the listed entities.which includes the name, description of operations, employee count and locations.

Secure upload of relevant documents here:

PDF files preferred

Additional Information & Comments