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CRIME PROTECTION PLUS THIRD PARTY ADMINISTRATOR SUPPLEMENT (Philadelphia Insurance Companies)

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CRIME PROTECTION PLUS
THIRD PARTY ADMINISTRATOR SUPPLEMENT
This is a supplement to the Philadelphia Insurance Companies Crime Protection Plus Application
Name of Applicant:
1.
Do your clients audit your services?
Yes
No
If yes:
a.
How is the audit performed?
b.
How frequently?
2.
Describe the services you provides for your clients:
Premium Collection
Other: (describe)
3.
If you collect funds for clients, please indicate the following:
a.
Maximum amount / client / month:
$
b.
Average amount / client / month:
$
4.
How often do you remit premium collections to your clients?
5.
Are premium payments sent directly:
To You
To a Bank or Lock box
6.
Are the duties of receiving premium payments, recording the payments, making deposits and
account reconciliation split between different employees?
Yes
No
7.
In what areas, excluding premium collection and claim settlement, do you handle client funds?
8.
Do your clients use “0” balance fund? (i.e. client replenishes the account after reconciling the
payment made to the claimant by you)
Yes
No
9.
Do you have a claims handling and procedures manual?
Yes
No
10.
What is your maximum claim payment authority? $
11.
How many of your employees have the ability to issue claim checks?
12.
Is a countersignature of claims and other checks required?
Yes
No
If yes:
a.
At what limit? $
b.
Who signs?
13.
Are claims handling reports prepared for use by:
You
Clients
How often for each?
You:
Clients:
Crime Protection Plus
Third Party Administrator Supplement
Page 1 of 3
© 2017 Philadelphia Consolidated Holding Corp.
08/2017
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14.
Do you have procedures in place to prevent payments against a closed file?
Yes
No
15.
What procedures are in place to guard against the payment of fictitious claims?
To enter more information, please use the separate page attached to the application.
I understand information submitted herein becomes a part of my Philadelphia Insurance Companies Accountants
Professional Liability Application and is subject to the same conditions as stated on the application.
Name (Please Print)
Title
_______________________________________________
Signature
Date
Crime Protection Plus
Third Party Administrator Supplement
Page 2 of 3
© 2017 Philadelphia Consolidated Holding Corp.
08/2017
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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
Third Party Administrator Supplement
Page 3 of 3
© 2017 Philadelphia Consolidated Holding Corp.
08/2017
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CRIME PROTECTION PLUS THIRD PARTY ADMINISTRATOR SUPPLEMENT (Philadelphia Insurance Companies)

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Completed 29 July 2020

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