Fillable CRIME PROTECTION PLUS APPLICATION (for limits less than (Philadelphia Insurance Companies)

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CRIME PROTECTION PLUS APPLICATION (for limits less than (Philadelphia Insurance Companies)

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CRIME PROTECTION PLUS APPLICATION
(for limits less than $1,000,000)
Name of Applicant: (Include Employee Benefit Plans to be named for ERISA Fidelity coverage)
Address:
City: State: Zip code:
Effective dates of current Crime coverage:
Website address: www.
Predominant business activity:
SIC code:
Year business started: Annual sales or revenue:
$
Limit Deductible
Insuring Agreement A1: Employment Theft and client coverage $ $
Insuring Agreement A2 ERISA Fidelity $ $
Insuring Agreement B: Forgery or Alteration $ $
Insuring Agreement C: Theft, Disappearance & Destruction –
Inside the Premises $ $
Insuring Agreement D: Theft, Disappearance & Destruction –
Outside the Premises $ $
Insuring Agreement E: Money Orders and Counte
rfeit Paper
Currency $ $
Insuring Agreement E: Computer and Funds Transfer Fraud $ $
Third Party – “Off Premises” coverage: Yes No If yes, complete the Third Party Crime Protection Plus
Supplemental
Coverage on a: Discovery basis: Loss Sustained basis:
Current Insurer: Limit: $
Deductible: $ Premium: $
Loss Experience:
1. List all crime losses sustained during the last three (3) years whether reimbursed or not. Check here if none:
Date of loss: Total amount of loss: $
Description of loss and corrective action:
Crime Protection Plus Application (05/10)
Page 1 of 4
© 2014 Philadelphia Consolidated Holding Corp.
04/2014
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Date of loss:
Total amount of loss: $
Description of loss and corrective action:
To enter more information, please use the addition information section included in the application
Classification of Employees:
US/Canada
Other Countries Total
1. Total number of employees*:
2. Locations: (Other than main office)
*Number of employees that are: Leased: Temporary: Non-Compensated:
Hiring Procedures / Employment Practices:
1. Do you conduct 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
Internal Controls:
1. Are your financial statements prepared by an independent Certified Public Accountant on an annual basis?
Yes No If yes, on what basis? ` Yes No
2. Are the owner(s) involved in the daily operations of the company? Yes No
3. Are two signatures required on check
s? If yes, over what amount? $ Yes No
If two (2) signatures are not required, who has the authority to sign checks?
Please provide their name and position:
4. Do employees who reconcile the bank statements also:
a. sign checks? Yes No
b. make withdrawls? Yes No
c. make deposits? Yes No
d. have access to blank checks? Yes No
e. have access to compute systems that print checks? Yes No
f. have access to facsimile, signature plate or check signing machines? Yes No
5. Do you have a system to detect payments to fictitious suppliers? Yes No
Money, Securities and Payroll Exposures:
1. Please indicate maximum exposure for each location if requesting Insuring Agreement C or D:
Locations
Cash Retail Checks Credit Card Is there a safe?
Receipts and Non-
Retail Checks*
$ $ $ Yes No
$ $ $ Yes No
$ $ $ Yes No
$ $ $ Yes No
$ $ $ Yes No
Material Change
If there is any material change to the answers of this Application’s questions prior to the policy inception date, the
Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or withdrawn.
Crime Protection Plus Application (05/10)
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© 2014 Philadelphia Consolidated Holding Corp.
04/2014
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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 C RIME 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, 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 L OSS 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: 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 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 COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A C RIME 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.
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.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRINCIPAL, PARTNER OR
OFFICER)
____________________________________________________
SIGNATURE DATE
Produced By: (Section to be completed by Producer/Broker)
PRODUCER AGENCY
PRODUCER LICENSE NUMBER AGENCY TAXPAYER ID OR SS NUMBER
ADDRESS (STREET, CITY, STATE, ZIP)
Crime Protection Plus Application (05/10)
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© 2014 Philadelphia Consolidated Holding Corp.
04/2014
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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 Application (05/10)
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© 2014 Philadelphia Consolidated Holding Corp.
04/2014
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CRIME PROTECTION PLUS APPLICATION (for limits less than (Philadelphia Insurance Companies)

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Completed 29 July 2020

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