Insurance FMI Application

INSURANCE FMI APPLICATION

Applicant / Insured Information

Corporation LLC Partnership Individual

Policy Details

Policy Period: From to

Coverage Options (select all that apply)

Employee Dishonesty

Money and Securities

Forgery or Alteration

Computer Fraud

Funds Transfer Fraud

Transit Coverage

Limits, Deductibles and Sublimits

Prior Insurance and Loss History

Has the applicant had similar insurance in the past five years? Yes No

Beneficiary / Loss Payee

Documentation Checklist

Most recent financial statements

Current employee list with positions and access levels

Bank account and transit documentation

Prior policy declarations (if available)

Exclusions and Important Conditions

Coverage under this policy is subject to express exclusions including, but not limited to: loss arising from war, nuclear hazard, willful criminal acts by the named insured, inventory shortage not resulting from a covered loss, and dishonest acts of an insured who is an owner, partner or principal unless specifically endorsed. The insurer retains subrogation rights and will seek recovery from responsible third parties where permitted by law.

Applicant acknowledges that coverage may be conditioned upon examination of books, records and other corroborating documentation. Failure to provide requested documentation or material misrepresentation of facts may result in denial of coverage or rescission of the policy.

By checking the box below the applicant acknowledges receipt and review of the policy exclusions and conditions and understands that coverage will be binding only if a policy is issued and premium paid.

Applicant acknowledges and accepts exclusions and conditions as stated above

Representations, Authorization and Fraud Warning

The undersigned represents that all statements and answers in this application are true, complete and made with the intent that they be relied upon by the insurer in determining whether to issue the requested policy and on what terms. The applicant understands that any fraudulent statements, material omissions or concealment of facts may render any resulting policy voidable, or may permit the insurer to deny coverage for a claim.

The undersigned authorizes the insurer and its representatives to investigate any matters relating to this application, to obtain and review financial and employment records, claim history and any other information reasonably required to evaluate the application. The applicant further authorizes disclosure of underwriting and claims information to reinsurers and law enforcement where required or permitted by law.

Fraud Warning: Any person who knowingly and with intent to defraud an insurer submits an application containing false information or conceals information may be subject to civil remedies and criminal prosecution under applicable law. Such consequences may include denial of claims, policy rescission and reporting to regulatory authorities.

Additional Information

Applicant Certification and Signature

The undersigned hereby certifies that the information contained in this application and any attachments is true and complete to the best of their knowledge and belief. Acceptance of this application by the insurer does not constitute a waiver of any rights of the insurer to contest coverage based on misrepresentation, nondisclosure or breach of conditions. The undersigned further certifies that they are authorized to submit this application on behalf of the named insured.

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