Insurance Crime Renewal Application

INSURANCE CRIME RENEWAL APPLICATION

Applicant / Insured Information

Applicant Name:

Individual    Corporation    Partnership    Limited Liability Company    Other:

Policy Information

Employee Dishonesty    Forgery or Alteration    Funds Transfer Fraud    Computer Fraud    Money & Securities    ERISA Fidelity    Other:

Current Controls and Security Measures

Number of employees with access to funds or securities:

Dual signatures for disbursements    Monthly bank reconciliation    Positive pay or equivalent banking controls    Dual custody of cash/securities    Pre-employment background checks   

Background checks performed: Yes    No    If yes, most recent date:

Firewall and network monitoring    Enforced password and access controls    Encryption of funds transfer credentials    Two-factor authentication for fund transfers

Prior Loss History (Last 5 Years)

Have there been any losses, claims, or incidents potentially covered by this policy since last renewal? Yes    No

Documentation Checklist

Please attach or indicate documents provided with this application:

Last 3 years financial statements    Sample bank reconciliation    Background check policy    Copies of prior loss reports   

Exclusions and Acknowledgment

The coverage sought under this application is subject to the policy terms, conditions and exclusions. Typical exclusions include but are not limited to: losses arising from war or governmental action; punitive or exemplary damages; losses caused by insured persons acting in bad faith known to the applicant prior to application; loss resulting from inventory shortage or clerical error unless caused by a covered act of fraud; and losses arising from fraudulent or dishonest acts not discovered within the policy discovery period. The insurer reserves the right to apply additional specific exclusions based on underwriting.

By checking the box below, Applicant acknowledges they have read and understand that coverage is subject to policy exclusions and endorsements and that failure to disclose material information may result in denial of coverage or rescission.

Applicant acknowledges exclusions and understands coverage is subject to policy language

Beneficiary / Loss Payee

If proceeds are payable to a named loss payee or beneficiary, complete below. If none, enter "None".

Declarations, Authorization and Certification

The undersigned Applicant declares that to the best of their knowledge the statements contained in this application are true and complete. Applicant warrants that no material facts have been omitted. Applicant understands that this application, including attachments and any materials submitted herewith, will be relied upon by the insurer in determining whether to issue or renew coverage and on what terms.

Applicant further authorizes the insurer and its representatives to make inquiry and investigation into any matters pertaining to the underwriting of the insurance requested, including but not limited to: verification of prior claims, credit checks, background checks, and inspection of relevant records and premises. Applicant agrees to provide, upon request, originals or certified copies of documents referenced in this application.

It is agreed that the insurance, if issued, will be upon the insurer's standard policy forms and endorsements. No coverage is bound or effective unless and until approved in writing by an authorized representative of the insurer. Any insurance premium quotations or interim coverages are subject to the insurer's underwriting review and acceptance of this application.

The Applicant understands that any false statement, misrepresentation or concealment of a material fact may result in denial of coverage, cancellation of the policy, or refusal to pay claims. The Applicant agrees to notify the insurer immediately of any material change in condition occurring prior to the effective date of any policy issued in reliance on this application.

Sign Now