third_party

Third Party Crime Bond Form

Call us at 800-921-1008 with any questions

Applicant means all corporations, organizations or other entities, including subsidiaries that are proposed for this insurance

I. GENERAL INFORMATION

1. Name of Applicant

Phone Number

Email

Address

State

Expiring Policy Number*

* Expiring Policy Number need not be completed if a separate first party crime application Is also being completed.

II. THIRD PARTY CRIME CONTRACT SPECIFIC COVERAGE
Skip this Section II if Third Party Crime Blanket Coverage is desired.

1. Name of contracted client:

2. Total number of employees providing services to the client under terms of the contract:

3. Describe the specific services provided to the client under terms of the contract:

4. Are any services performed for contracted clients off the clients’ premises?

Yes No

5. Are you presently bidding on this contract?

Yes No

6. Is this contract presently in effect?

Yes No

please list effective and expiration dates of the contract.

7. Annual gross dollar value of the contract:

III. THIRD PARTY CRIME BLANKET COVERAGE
Skip this Section III if Third Party Crime Contract Specific Coverage is desired.

1. Total number of employees providing services for contracted clients:

2. Total number of client contracts currently in place:

3. Describe the services provided by your employees while on your contracted clients’ premises:

4. Are any services performed for contracted clients off the clients’ premises?

Yes No

IV. UNDERWRITING INFORMATION

1. Do you verify the employment background of prospective employees?

Yes No

Prior employment verification

Yes No

Drug testing

Yes No

Education verification

Yes No

Credit history

Yes No

Criminal history

Yes No

Other

Yes No

2. Do you use non-employees to perform contracted client services?

Yes No

How Many?

3. Describe supervisory procedures for all individuals engaged in performing contracted client services:

4. Do you assess the services provided by your employees for contracted clients at least annually?

Yes No

5. 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.
Check here if no losses

No Losses

V. REQUESTED INSURANCE TERMS

Requested Limit

Requested Deductible

VI. REQUIRED ATTACHMENTS – THIRD PARTY CRIME

As part of this Application, please submit the following 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

Secure upload of relevant documents here:

PDF files preferred

Additional Information & Comments