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Fidelity/Dishonesty Bond Form

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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 Letter.

10. For your most recent fiscal year end please complete the following financial information:

Fiscal Year End Date:

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.


1. Does someone other than the person responsible for reconciling bank accounts:

4. Is segregation of duties practiced in the following areas:

7. Indicate if you have or perform any of the following during the hiring process:

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.


Desired Crime Coverage

Fidelity: Employee Theft

Fidelity: ERISA Fidelity

Fidelity: Employee Theft of Client Property

Forgery or Alteration

On Premises (Money, Securities and Other Property)

In Transit (Money, Securities and Other Property)

Money Orders and Counterfeit Money

Computer Crime + Funds Transfer Fraud

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:

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 locations.

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:

PDF files preferred
PDF files preferred