This Application will only be accepted for Privately held commercial companies
and Non-Profit organizations with:
• 250 or fewer employees and $100 million or less in assets and $100
million or less in revenues
This Application will not be accepted for Public Companies, Government
Entities or Financial Institutions.
Applicant means all corporations, organizations or other entities, including
subsidiaries and Employee Benefit Plans subject to ERISA, that are proposed
for this insurance in Item I. APPLICANT INFORMATION.
Third-party fidelity bonds protect businesses against intentionally wrongful
acts committed by people working for them on a contract basis (e.g., consultants
or independent contractors).
2. Does the Applicant wish to include additional entities (e.g., affiliates,
partnerships, joint ventures) as insureds for coverage?
Complete the following table indicating all additional entities for which
coverage is requested:
*IMPORTANT NOTE: Receipt of this information does not constitute an agreement
that coverage will be provided to the listed entities.
3. Total number of employees** at all locations
4. Total number of volunteers (only if Applicant is a non-profit organization)
5. Total number of locations:
6. a. Number of locations outside the United States:
Indicate domicile of each location on a separate page.
b. Number of employees* domiciled outside the United States:
*Employee count should include full time and part time employees (including
leased, seasonal and temporary).
7. Indicate the total amount of specified property INSIDE the premises
for all locations combined:
8. Indicate the total amount of specified property being transported by
a messenger OUTSIDE the
premises for all locations combined:
**Retail Checks are only those checks that are accepted as immediate payment
for retail products or services.
Note: Omit Question 10. if the limit requested is $5,000,000 or greater,
and attach the most recent annual financial statement and CPA Management
10. For your most recent fiscal year end please complete the following
11. During the past 24 months has the Applicant experienced, or during
the next 12 months does the Applicant anticipate, any reorganization or
arrangement with creditors under federal or state law? If Yes, please attach
an explanation with full details of the circumstances of such an event.
II. INTERNAL CONTROL INFORMATION
1. Does someone other than the person responsible for reconciling bank
4. Is segregation of duties practiced in the following areas:
7. Indicate if you have or perform any of the following during the hiring
12. Indicate any of the following characteristics or exposures that apply
to your business operations:
If you checked any of the characteristics or exposures above, please provide
details that quantify the exposure and briefly describe the controls in
place to protect you from loss in a separate attachment.
III. CURRENT INSURANCE INFORMATION/REQUESTED INSURANCE TERMS
Fidelity: Employee Theft of Client Property
On Premises (Money, Securities and Other Property)
In Transit (Money, Securities and Other Property)
Money Orders and Counterfeit Money
Computer Crime + Funds Transfer Fraud
THIRD PARTY CRIME CONTRACT SPECIFIC COVERAGE
Skip this section if Third Party Crime Blanket Coverage is desired
Name of contracted client
Total number of employees providing services to the client under terms
of the contract
Annual gross dollar value of the contract:
THIRD PARTY CRIME BLANKET COVERAGE
Skip this section if Third Party Crime Contract Specific Coverage is desired
Total number of employees providing services for contracted clients
Total number of client contracts currently in place
List and describe all losses sustained by contracted clients and caused
by your dishonest employee during the past 5 years, whether or not you
were reimbursed by insurance. Include corrective actions taken.
Has the Applicant or any proposed insured sustained any crime-related
losses in the past 3 years? If Yes, please write a full explanation of
the loss including date, description, status of the loss, amount of the
loss and procedures implemented to avoid further losses.
As part of this Application, please submit the following documents: Most
recent annual financial statement, and CPA Management Letter, for limit
requests of $5,000,000 or greater.
For each additional entity for which coverage is requested please attach
a separate page or an organization chart
which includes the name, description of operations, employee count and
Third Party Crime Required Documents:
• (If Blanket Coverage is desired) Specimen copy of the contract
used for all clients
• (If Contract Specific Coverage is desired) A copy of the entire
contract which requires Third Party Crime Coverage,
specifically the section which details the work to be performed
Important Note: Receipt of this information does not constitute an agreement
that coverage will be provided to the listed entities.which includes the
name, description of operations, employee count and locations.
Secure upload of relevant documents here: