F-3175 - Crime Insurance Application Form Page 2
Download a blank fillable F-3175 - Crime Insurance Application Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete F-3175 - Crime Insurance Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2TO BE ANSWERED WHEN APPLYING FOR LIMITS OF GREATER THAN $1,000,000 ONLY
1. Is segregation of duties practiced in the following areas:
Purchasing? ....
Yes
No
Inventory? ............
Yes
No
Disbursements?....
Yes
No
Payroll?....
Yes
No
2. Are the duties of the computer programmers and operators separated? ......
Yes
No
When answering the following questions, please consider all subsidiaries, affiliates and locations, including those outside of the
United States. Please attach your most recent year-end CPA-prepared financial statement. For limits of $5,000,000 or more,
please attach a copy of your most recent CPA Letter to Management and Responses.
1. Do you engage an independent CPA for an annual audit?
Yes
No
2. Have you adopted all material recommendations of the CPA
Yes
No
No Recommendations
3. Do you have an internal audit department?
Yes
No
If yes, does it report directly to the Board of Directors/Audit Committee?
Yes
No
Are all locations audited?
Yes
No
Please mark any of the following characteristics or exposures that apply to your company’s operation:
______ Precious metals or gemstones
______ Narcotics
______ Warehouse operation
______ Proprietary credit card operation
______ Care, custody and control of clients’ property
______ Joint ventures
______ Employee credit cards
______ High unit-value, portable inventory
______ Cash exposure greater than the deductible
______ Active participation in more than one industry
______ Private collections of art and other collectibles
If you checked any of the exposure characteristics, please provide an attachment that quantifies the exposure and briefly describes the
controls in place to protect you from loss.
C
I
C
URRENT
NSURANCE
OVERAGES
Policy
Limit
Deductible
Insurance Co.
Eff. Date
Premium
Directors & Officers
Employment Practices
Fiduciary Liability
Attention: Insureds in KY
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
________________________________________________________________________________________________________
Date
Signature
Title
F-3175 (02-00)
Page 2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal