General Information

Date:

Named Insured:

D/B/A:

Address:

City, State:

Phone:

Named Insured is a:     _____Individual     _____Partnership     _____Corporation

          ____Limited Liability Corp.     _____Joint Venture     _____Other

General business operations:

States/territories in which insured has operations:

States/territories in which insured may begin operations within next twelve months:

Loss control contact name/phone:

Insurance Company Information

Carrier name ___________________________________________________

Financial (A.M. Best) rating ____________________________________

Premium ____________________________________

Number of days for notice of cancellation & non-renewal _____________

Has there been continuous coverage with one carrier since crime coverage has been carried? If not, do replacement policies include a superseded suretyship provision? ___________________________________________

Standard or non-admitted market? _________________________________

Coverage territory ____________________________________________

Common Coverage and Limits

Employee Theft, Insuring Agreement One:_________________________________

Forgery or Alteration, Insuring Agreement Two: _____________________________

Theft Of Money & Securities, Inside the Premises, Insuring Agreement Three: _______________________________

Robbery or Safe Burglary of Other Property, Insuring Agreement Four: _______________________________

Outside the Premises, Insuring Agreement Five: _______________________________

Computer Fraud, Insuring Agreement Six: ________________________

Money Orders and Counterfeit Paper Currency, Insuring Agreement Seven _________________________

Loss Control Items (General Crime Exposures)

	Yes	No
Are standard accounting procedures being used?	___	___
Are audits conducted at least annually by a firm or individual from outside the organization?	___	___
Is inventory included in the audits, if applicable?	___	___
Are all locations audited?	___	___
Is the audit report given directly to the owner or board of directors?	___	___
Are internal audits periodically conducted by an internal audit department?	___	___
What are the time intervals between these audits?	___	___
Are bank accounts reconciled by someone not authorized to deposit or withdraw from them?	___	___
Is counter signature of checks required?	___	___
Are securities subject to joint control of two or more employees?	___	___
Are all employees and officers required to take annual vacations of at least five consecutive business days?	___	___
Are checks stamped “for deposit only” immediately upon receipt?	___	___
How frequently are bank deposits made? Are messengers who make deposits accompanied by guards and do they vary their route to the deposit institution?	___	___
If an armored car service is used, review contract to determine whether appropriate insurance is being provided.	___	___
Are locations equipped with an alarm system?	___	___