Fillable CRIME PROTECTION PLUS APPLICATION (for limits $1,000,000 and (Philadelphia Insurance Companies)

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CRIME PROTECTION PLUS APPLICATION (for limits $1,000,000 and (Philadelphia Insurance Companies)

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CRIME PROTECTION PLUS APPLICATION
(for limits $1,000,000 and greater)
Agent:
Name of Applicant: (Include Employee Benefit Plans to be named for ERISA Fidelity Coverage)
Address:
City:
State:
Zip:
Effective Date:
Predominant Business Activity:
SIC Code:
Year Business Started:
Annual Sales or Revenue: $
Desired Coverage(s):
Limit
Deductible
Insuring Agreement A1:
$
$
Insuring Agreement A2:
$
$
Insuring Agreement B:
$
$
Insuring Agreement C:
$
$
Insuring Agreement D:
$
$
Insuring Agreement E:
$
$
Insuring Agreement F:
$
$
Third Party – “Off-Premises” Coverage –
Yes
No
If yes, please complete the Third Party Crime Protection Plus Supplemental
Coverage on a:
Discovery Basis
Loss Sustained Basis
Current Insurer:
Limit:
$
Deductible: $
Premium:
$
Loss Experience:
List all crime losses sustained during the last three years whether reimbursed or not.
Check here if none:
Date of Loss:
Total Amount of Loss: $
Description of Loss and Corrective Action:
Date of Loss:
Total Amount of Loss: $
Description of Loss and Corrective Action:
To enter more information, please use the separate page attached to the application.
Crime Protection Plus
(Limits $1 Million and over)
Page 1 of 5
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
Clear Application
Print Application
Classification of Employees:
US/Canada
Other Countries
Total
Total Number of Employees*
Locations (Other than Main Office)
*Number of employees that are:
Leased:
Temporary:
Non-Compensated:
Hiring Procedures/Employment Practices:
1.
Do you conduct a prior employment check on all new hires?
Yes
No
2.
Do you conduct a criminal background check on all new hires?
Yes
No
3.
Do you conduct a criminal background check on current employees?
Yes
No
4.
Are credit reports checked when screening new employees?
Yes
No
Audit Procedures:
1.
Are your financial statements prepared by an independent Certified Public Accountant on an
annual basis?
Yes
No
If yes, on what basis?
Compilation
Review
or Audit
Please attach a copy of your most recent financial statement.
2.
Are all subsidiaries and locations, or majority-owned and operated companies, included in the
audit?
Yes
No
3.
Have all recommendations made by the accountant been adopted?
Yes
No
4.
Do you have an Internal Audit Department?
Yes
No
If not, is there someone who is responsible for internal control procedures?
Yes
No
5.
If any weaknesses are noted, is the department in question notified in writing by the Internal
Audit Department and are corrective actions monitored?
Yes
No
Internal Controls:
1.
Are the owner(s) involved in the daily operations of the company?
Yes
No
2.
Are two signatures required on checks?
Yes
No
If so, over what amount? $
If two signatures are not required, who has authority to sign checks? Please provide
their name and position:
3.
Do employees who reconcile the bank statements also:
a.
sign checks?
Yes
No
b.
make withdrawals?
Yes
No
c.
make deposits?
Yes
No
d.
have access to blank checks?
Yes
No
e.
have access to computer systems that print checks?
Yes
No
f.
have access to facsimile, signature plate, or check-signing machines?
Yes
No
4.
Is a facsimile or signature plate used?
Yes
No
a.
Is it kept in a safe?
Yes
No
If not, where is it kept?
b.
Who has access to the plate?
c.
Is a record kept of its use?
Yes
No
5.
Are your internal control systems designed so that no one employee can control a transaction
from beginning to end (e.g. approve a voucher, request and sign a check)?
Yes
No
6.
How often is blank check stock inventoried?
By whom?
7.
Are all incoming checks stamped “For Deposit Only” immediately upon receipt?
Yes
No
Purchasing, Vendor and Inventory Controls:
1.
Are perpetual inventories maintained of materials and supplies and periodically verified by
physical count?
Yes
No
2.
Do you have a security alarm system and video camera to protect your inventory in all locations?
Yes
No
Crime Protection Plus
(Limits $1 Million and over)
Page 2 of 5
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
Clear Application
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3.
Are background checks performed on vendors in order to determine ownership and capability
prior to doing business with them?
Yes
No
4.
Is the responsibility for authorizing vendors, approving invoices and processing payment
segregated among different individuals?
Yes
No
5.
Do you have a system to detect payments to fictitious suppliers?
Yes
No
Computer Controls:
1.
Are pre-authorization controls maintained for all programmers and operators?
Yes
No
2.
Are the duties of programmers and operators separated?
Yes
No
3.
Are “tests” performed to detect unauthorized programming changes?
Yes
No
4.
Are computerized check writing operations segregated from departments that authorize checks?
Yes
No
5.
Are passwords and system access immediately terminated for inactive and terminated
employees?
Yes
No
Wire Transfer Controls: (Skip this section if you do not utilize wire transfers.)
1.
Is there one employee responsible for wire transfers?
Yes
No
If yes, what position does this person hold?
If no, who initiates wire transfer requests?
2.
What is your average daily number of funds transferred?
3.
What is the largest single amount that can be transferred? $
4.
Are banks required to authenticate the identity of the caller before acting upon the instructions?
Yes
No
If yes, how is this achieved?
5.
Does the receiving financial institution immediately verify the completion of transfer of funds?
Yes
No
If yes, does this verification go to an employee other than the one who initiated the transfer?
Yes
No
6.
Are there specific arrangements with the financial institution as to the individuals in your
company authorized to:
a.
transfer funds?
Yes
No
b.
request changes in procedures?
Yes
No
c.
obtain records?
Yes
No
7.
Are independent checks of funds transfer records performed by staff not authorized to
handle/instruct such transactions?
Yes
No
Money, Securities and Payroll Exposure:
Please indicate maximum exposure for each location if requesting Insuring Agreement C or D:
Location(s)
Cash
Retail Checks
Credit Card Receipts
and Non Retail
Checks*
Is there a
Safe?
$
$
$
Yes
No
$
$
$
Yes
No
$
$
$
Yes
No
$
$
$
Yes
No
*A non-retail check is a check presented to you and immediately endorsed “for deposit only” and then recorded in your
accounting process so that it could be re-created if it were stolen, lost or destroyed.
Crime Protection Plus
(Limits $1 Million and over)
Page 3 of 5
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION
CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY. PENALTIES MAY INCLUDE
IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES. ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO
KNOWINGLY PROVIDES FALSE, INCOMPLETE, OR MISLEADING FACTS OR INFORMATION TO A POLICYHOLDER OR CLAIMANT FOR THE PURPOSE
OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM
INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY
AGENCIES.
APPLICABLE IN FLORIDA AND OKLAHOMA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER
FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A
FELONY (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT,
FINES OR A DENIAL OF INSURANCE BENEFITS.
APPLICABLE IN PENNSYLVANIA: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
APPLICABLE IN NEW YORK: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A
CRIME AND SHALL BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_____________________________________________________________
SIGNATURE DATE
SECTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Crime Protection Plus
(Limits $1 Million and over)
Page 4 of 5
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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ADDITIONAL INFORMATION
This page may be used to provide additional information to any question on this application.
Please identify the question number to which you are referring.
_______________________________________
Signature Date
Crime Protection Plus
(Limits $1 Million and over)
Page 5 of 5
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
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CRIME PROTECTION PLUS APPLICATION (for limits $1,000,000 and (Philadelphia Insurance Companies)

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Completed 29 July 2020

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