F-3175 - Crime Insurance Application Form
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1
2C I T Y U N D E R W R I T I N G A G E N C Y , I N C .
APPLICATION
CRIME INSURANCE APPLICATION
Name:___________________________________________________ SIC Code:__________ Agent:_______________________
(If more than one Insured or if including employee benefit plans, please attach a list)
Agent Code: __________________
Address: ____________________________________________________________________
City: _____________________________________ State:______________ Zip: ___________ Effective Date: ________________
Predominant Business Activity: _________________________________________________ Billing:
Year Business Started:________________ Annual Sales or Revenue: ___________________
Installment
Prepaid
Are you a publicly-traded company?
Yes
No If yes, ticker symbol ___________
D
C
L
L
ESIRED
OVERAGE
IMITS OF
IABILITY
If all six coverages identified below are desired at the same limit:
$ _____________________
or, if varying limits or coverages are desired:
•
Employee Dishonesty
$ _____________________
•
Forgery or Alteration
$ _____________________
•
On Premises (Money, Securities, and Other Property)
$ _____________________
•
In Transit (Money, Securities, and Other Property)
$ _____________________
•
Money Orders and Counterfeit Paper Currency
$ _____________________
•
Computer Fraud and Funds Transfer Fraud
$ _____________________
•
Other:
$ _____________________
Deductible: $ ______________________
Prior Insurer: ______________________ Limit: $ _______________ Deductible: $ _______________ Premium: $___________
L
E
:
OSS
XPERIENCE
List all crime losses sustained during the last three years whether reimbursed or not. Check here if none
Date of Loss
Total Amount of Loss
Description of Loss and Corrective Action
________________________________________________________________________________________________________
________________________________________________________________________________________________________
US/Canada
Other Countries
Total
Number of Employees *
__________
______________
_________
Locations (other than main office)
__________
______________
_________
*Includes the following employees: Leased:_______ , Temporary: _______ , and Non-compensated Employees:
.
Are any employees compensated with commissions, based on sales activity, that on average
exceeds 50% of their base salary? ................................................................................................................
Yes
No
Companies that practice segregation of duties and perform background checks on new employees have a better opportunity to either prevent
or detect employee dishonesty. Segregation of duties means that no single employee can control a process or transaction from beginning to
end.
1.
Are officer-shareholders active in the day to day operation of the business? ......................................
Yes
No
2.
Do employees who reconcile the bank statement also :
Make deposits? ............
Yes
No
Make withdrawals? .....
Yes
No
Sign checks? ....
Yes
No
3.
Is a CPA involved in the applicant’s financial reporting?....................................................................
Yes
No
4.
For new employees, are background checks which may include prior employment,
criminal history or drug testing performed?.........................................................................................
Yes
No
Please indicate maximum exposure for each location:
Credit Card Receipts
Is there a Safe?
Locations
Cash
Retail Checks
and Non-retail Checks**
(Y or N)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
** A non-retail check is a check presented to you and immediately endorsed “for deposit only” and then recorded in your accounting process
so that it could be recreated if it were stolen, lost or destroyed.
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