Insurance Crime Application

INSURANCE CRIME APPLICATION

Applicant / Insured Information

Contact phone:     Email:

Date of birth / formation date:     Tax ID / SSN:

Policy Details

Proposed policy number (if renewal):     Coverage limit requested: $

Deductible: $     Annual premium quoted: $

Policy period from:     to:

Coverage Selection

Select coverages requested (check all that apply):

Employee Dishonesty    Limit: $

Forgery or Alteration    Limit: $

Inside the Premises — Theft of Money and Securities    Sublimit: $

Outside the Premises    Sublimit: $

Computer Fraud    Limit: $

Funds Transfer Fraud    Limit: $

Social Engineering / Impersonation    Limit: $

Exclusions and Acknowledgement

Standard policy exclusions typically include, without limitation: dishonest acts by insureds or partners not disclosed to insurer, losses due to war or nuclear hazard, contractual liability beyond policy terms, punitive damages where uninsurable by law, loss resulting from inventory shortages undetected by acceptable audit procedures, and criminal acts by insured principals unless specifically endorsed. Applicant must review the policy form to determine full exclusions.

I acknowledge that I have read and understand that the policy contains exclusions and limitations. I further acknowledge that additional exclusions may apply to specific endorsements.

Security Controls and Risk Management

Please indicate which of the following controls are in place:

Background checks for employees handling funds

Employee fidelity bonding in place

Dual-signature requirements for wire transfers and withdrawals

CCTV or monitored surveillance of cash-handling areas

Monthly reconciliations by independent personnel

Prior Loss History

List all losses, claims or incidents involving theft, fraud or dishonesty in the last 5 years. Attach supporting documentation where available.

Beneficiary / Payee Information

Provide name(s) and allocation for payee(s) to receive indemnity payments in the event of claim settlement.

Relationship:     Allocation:

Relationship:     Allocation:

Declarations and Certifications

The undersigned certifies that the statements and particulars contained in this application are true and complete to the best of the applicant's knowledge and belief. The undersigned understands that any material misrepresentation, omission or incorrect statement in this application may result in denial of coverage or rescission of any policy issued based on this application.

By submitting this application the applicant authorizes the insurer and its representatives to make inquiries and obtain records, including but not limited to employment and background checks, loss history, financial information and other records necessary to evaluate coverage. This authorization remains valid for the underwriting and claim investigation process.

I declare under penalty of perjury that the foregoing is true and correct. I agree to notify the insurer of any material change in the risk prior to policy inception and acknowledge that coverage is not in effect until a policy is issued and premium paid.

I certify that the information provided in this application is true and authorizing the insurer to investigate and verify any statements herein.

Signature

The person signing below warrants that they are authorized to execute this application on behalf of the applicant and that signing represents acceptance of the declarations and acknowledgements contained herein.

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