Crime/Employee Dishonesty
Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way.  If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. 
Business Information
Name of Business:
Contact Name:
E-mail Address:
Business Address:
City:
State:
Zip:
Mailing Address (if different from above):
Phone:
Fax Number:
E-mail Address:

Coverage

Coverage

 Limit Deductible
Employee Theft:

$
ERISA (Total Asset Value)

$

$
Employee Theft Governmental Crime

$
Forgery or Alteration:

 

 $
Inside the Premises
Theft of Money and Securities:

$
Inside the Premises
Robbery or Burglary of Other Property:

$
Outside the Premises
Money and Securities:

$
Outside the Premises
Other Property:

$
Computer Fraud:   $
Funds Transfer Fraud:   $
Money Orders and Counterfeit Paper Currency: $
Coverage Endorsements

ERISA Employee Theft - Additional Information

Name of Plan

Principle Address

Number of trustees, employees,
etc. handling plan assets

Number of Plan Participants

Is there a licensed securities firm responsible for the investing of funds under plan(s)?Yes  No

General Information
1. Are volunteers used? If yes, explain how many in remarks section below.? Yes  No
2. Any employees leased to others? If yes, give number and explain in remarks section below. Yes  No
3. Any employees leased from others? If yes, give number and explain in remarks section below. Yes  No

4. Any employees perform money trading or investing?

 Yes  No

5. Any employees receive or issue warehouse receipts?

 Yes  No

6. Any employee(s) been cancelled for crime coverage by any insurer?

 Yes  No
7. Does applicant have any written agreements with clients? Yes  No
8. Does applicant transfer any funds via phone or fax? Yes  No
9. Any exposure from loss to guest property? Yes  No

Remarks

Classification Of Employees/Locations
Number Of Officers: 
Total Number of Other Employees:
Manufacturers, Processors, Wholesalers or Distributors; Number of Retail Locations:
All Other Classes; Number of Locations Other Than Home or Head Offices:

Controls and Audit Procedures
Is there an audit by?
Audit frequency:
Are all locations audited?
Is audit made in accordance with generally accepted auditing standards and so certified?

Premises/Safe Protection

Alarm Type:

Alarm Description:

Alarm Certificate Number

Number of Guards

Number of Watch Persons
   
Please note that this form is for a REQUEST ONLY. By submitting this form it does not bind coverage in any way.  If you do not hear from us in a reasonable amount of time, ASSUME WE DID NOT GET THIS REQUEST FOR AN INSURANCE QUOTE, and call our office.

I understand that filling out and submitting this form DOES NOT bind coverage in any way, and the only way coverage can be bound will be when I am informed of a binder or policy is issued by the agent representing me. 

I have read and agree with the above disclaimer (It is mandatory to check box before submitting)