141 Crime Form

Applicant name*
Effective date*
Expiration date*
Payment Plan
Audit
Basis for coverage
Coverage:
Employee theft
Blanket or schedule?
Limit ($)
Deductible ($)
Erisa?
Total asset value ($)
Limit ($)
Employee theft--Governmental crime
Blanket, schedule, per loss, or per employee?
Limit ($)
Deductible ($)
Forgery or Alteration
Limit ($)
Deductible ($)
Inside the premises--Theft of money and securities
Blanket or schedule
Limit ($)
Deductible ($)
Inside the premises--Robbery or burglary of other property
Blanket or schedule
Limit ($)
Deductible ($)
Outside the premises--Money and securities
Blanket or schedule
Limit ($)
Deductible ($)
Computer fraud
Limit ($)
Deductible ($)
Money orders and counterfeit paper currency
Limit ($)
Deductible ($)
Coverage Endorsements:
Explain
ERISA EMPLOYEE THEFT - ADDITIONAL INFORMATION:
Name of Plan
Principle Address
Address
City
State
Zip
Number of trustees, Employees, Etc. Handling Plan Assets
Number of plan participants
Licensed securities firm responsible for investing of funds under plan
General Information:
Explain all yes answers
Are volunteers used?*
Explain, how many?
Are employees leased to others?*
Explain, give number
Are employees leased from others?*
Explain, give number
Any employees perform money investing or trading?*
Explain
Any employees receive or issue warehouse receipts?*
Explain
Any employee(s) been cancelled for crime coverage by any insurer?*
Explain
Does applicant have any written agreements with clients?*
Explain
Does applicant transfer any funds via phone or fax?*
Explain
Any exposure from loss to guest property?*
Explain
Number of officers
Total number of other rateable employees
Manufacturers, processors, wholesalers, or distributors; number of retail locations
All other classes of locations other than home or head offices
Controls and Audit Procedures:
Audits
Is there an audit by...? If OTHER, explain.*
Explain
All locations audited?*
Is audit made in accordance with generally accepted auditing standards and so certified? If NO, explain*
Date of completion of last audit of cash and accounts
Date of completion of last audit of inventory
Were any discrepancies of loose practices commented upon in this audit?
Audit frequency. (if OTHER, explain)
Explain
Does audit include inventory?
Audit report is rendered to: (if OTHER, explain)
Explain
Banking/Other
Are bank accounts reconciled by someone not authorized to deposit or withdraw?
Is countersignature of checks required?
If countersignature is not required, who signs controls?
Will securities be subject to joint control of to or more responsible employees?
Are all officers and employees required to take annual vacations of at least five consecutive business days?
Money-Securities:
(enter exposures for each category, amounts entered should be maximum exposure:
Inside
Money ($)
Checks for deposit ($)
Checks for accounts payable ($)
Payroll checks ($)
Money overnight ($)
Securities (in bank/safe deposit)
Messenger #1
Money ($)
Checks for deposit ($)
Checks for accounts payable ($)
Payroll checks ($)
Money overnight ($)
Securities (in bank/safe deposit)
Messenger #2
Money ($)
Checks for deposit ($)
Checks for accounts payable ($)
Payroll checks ($)
Money overnight ($)
Securities (in bank/safe deposit)
Property:
Description of property, merchandise, stock, etc
Maximum value ($)
Miscellaneous Information:
Business hours
Average number of employees on duty
Checks stamped for deposit only
Frequency of deposits
Night depository used
Annual gross sales or receipts for last fiscal year ($)
Does premises have double cyclinder door locks?
Other information
Safe/Vault:
Manufacturer 1
Manufacturer name
Label
Class
Door type
Combination locks
Thickness of door (exclude boltwork)
Thickness of wall
Manufacturer 2
Manufacturer name
Label
Class
Door type
Combination locks
Thickness of door (exclude boltwork)
Thickness of wall
Messenger Protection:
Messenger 1
Messenger number
Number of guards per messenger
Private conveyance used?
Safety satchel used?
Messenger 2
Messenger number
Number of guards per messenger
Private conveyance used?
Safety satchel used?
Premises/Safe Protection:
Alarm type
Alarm description
Certificate number
Expiration date
Grade
Extent of protection of safe/vault
Extent of protection of premises
Alarm installed and serviced by
Number of guards
Number of watchpersons
Watchpersons
Accessible openings and protection
Other protection (fences, floodlights, etc)