Fillable Hiscox Insurance Company Inc. Executive Risks Crime Application (Special Risks)

Fill Online, Printable, Fillable, Blank Hiscox Insurance Company Inc. Executive Risks Crime Application (Special Risks) Form

Use Fill to complete blank online SPECIAL RISKS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Hiscox Insurance Company Inc. Executive Risks Crime Application (Special Risks)

On average this form takes 27 minutes to complete

The Hiscox Insurance Company Inc. Executive Risks Crime Application (Special Risks) form is 5 pages long and contains:

  • 0 signatures
  • 70 check-boxes
  • 76 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Special Risks forms online.

BROWSE SPECIAL RISKS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CSUCRI A0001A CW (05/18)
Hiscox Insurance Company Inc.
Executive Risks Crime Application C-Suite
NEW BUSINESS APPLICATION
READ THE POLICY AND THIS APPLICATION CAREFULLY AND CONSULT YOUR INSURANCE ADVISOR WITH ANY
QUESTIONS.
General Information
Name of Applicant:
Address of Applicant:
City: State: Zip Code:
Website Address: Date of Formation: / /
Description of Operations:
Please attach a list of all subsidiaries including operations, percent of ownership and the date acquired or created.
(Note: This application is for a policy which includes coverage for all subsidiaries under the Applicant’s control. The
application and any attachments must include information for the first named insured and all subsidiaries and other
entities to be included by endorsement).
Current or Requested Coverage
Premium Limit Deductible Clients’ Property
Current $ $ $ Yes No
Requested
$
$
Yes No
Financial Information
Current year: 20 Prior year: 20
Total assets: $ $
Total revenues: $ $
Net income / Change in net assets: $ $
Loss History
Check if none
List all losses sustained, whether or not claimed, and if claimed, whether or not reimbursed during the past six years from the
completion date of this application for any similar insurance requested in this application.
Date of loss
Type of loss
(Employee Theft, Forgery, etc…)
Amount of loss
/ / $
$
/ / $ $
Please attach full details of all losses including descriptions, corrective action taken, estimated ultimate total amount and amount
covered by insurance.
Exposure Information
Domestic Foreign
Grand Total
Number of employees:
1. Estimate the percentage of the Grand Total who have access to cash, checks and approval %
2. Total number of locations: If you provide lodging, how many guest rooms? n/a
3. For each foreign location, please detail the following information (attach separate sheet if necessary) Check if none
Country Type of operation # of employees Revenues
CSUCRI A0001A CW (05/18)
4. Are all controls consistent among all locations (including foreign locations)? Yes No
5. Maximum cash exposure (physical currency) Inside the Premises: $ Outside: $
6. Do you have precious metals, precious or semi-precious stones, pearls, furs or articles containing
such materials?
Yes No
If Yes, please provide details:
7. Do you have access to your client’s funds/property? Yes No
If Yes, type of property?
Dollar amount value: $ How many employees will be performing work for your client(s):
8. Have you or any subsidiary engaged in any mergers or acquisitions in the last three years? Yes No
Are there any plans for mergers or acquisitions in the next 12 months? Yes No
Audit Controls
1. Are your financial statements audited or reviewed annually by an independent CPA? Yes No
2. Is there a CPA Management Letter/ Response commenting on internal control weaknesses,
recommendations for improvement, and a response by management? If Yes, please attach the most
recent report.
Yes No
Were any material weaknesses identified during the audit which have not yet been implemented? Yes No
If Yes, please provide details:
3. Do you have an Internal Audit Department? If Yes, staff size? Yes No
Internal Controls
1. Please indicate the types of background checks performed for all new hires:
References Criminal Credit Checks Prior Employer
2. Are bank accounts reconciled monthly? Yes No
3. Are bank accounts reconciled by someone not authorized to deposit or withdraw? Yes No
4. Are internal controls designed so that no single employee can control a transaction from initiation to
recording/reconciliation? (e.g. request a check, approve a voucher and sign the check)
Yes No
5. Are at least two signatures required on checks? Yes No
If Yes, above what amount?
6. Are the owner(s) with more than 25% ownership the only individuals who can sign checks and make
deposits or withdrawals?
Yes No
7. Do you have a fraud hotline that is publicized to employees, vendors and customers? Yes No
8. Please indicate if fraud training is provided to: Executives Managers Employees
Vendor Controls
1. Estimated number of active vendors utilized:
2. Do you use vendors for handling financial transactions such as payroll and bookkeeping? Yes No
3. Is an authorized vendor list utilized and updated annually for all purchases, with competitive bidding
required?
Yes No
4. Are background checks performed on vendors in order to determine ownership and financial
capability?
Yes No
5. Is the responsibility for authorizing vendors, approving invoices and processing payments segregated
among different employees?
Yes No
Tech Controls
1. Are daily backups made and stored securely off premises? Yes No
2. Are employees warned of Phishing scams and blocked from harmful websites? Yes No
3. Are all desktop computers protected by anti-virus software? Yes No
4. Does your bank require authentication of the identity of the caller before acting upon any transfer
instructions?
Yes No
CSUCRI A0001A CW (05/18)
5. Are verifications sent directly to a department not authorized to initiate transfers?
Yes
No
6. Do you utilize login credentials belonging to any third party including customers and vendors? Yes No
7. With regard to transfer of funds:
Domestic Foreign
A) Daily average number:
B) Average amount transferred per day: $ $
C) Maximum amount in any one transfer: $ $
D) Percentage going to Asia / Russia combined:
%
8. Before acting on a transfer, do you verify the request or account detail changes using a method other
than the initial contact method (Example: the initial request is received by email and verification is
done by telephone). If Yes, above what amount?
Yes No
Describe procedure:
Are procedures followed for transfer requests coming from both internal and external sources? Yes No
9. Do you use email authentication to ensure that email originated from an authorized system?
(Example: SPF-Sender Policy Framework)
Yes No
Remainder of page intentionally left blank
CSUCRI A0001A CW (05/18)
APPLICATION DISCLOSURES:
If there is any material change in the answers to the questions in this Application before the proposed policy inception date, you
must notify us in writing. In such case, we have the right to cancel, withdraw, or modify any outstanding quote for insurance
coverage or any policy that may have been issued.
Your submission of this Application does not obligate us to issue, or require you to purchase, a policy. You authorize us to make
any inquiry in connection with this Application.
All written statements and materials provided to us in conjunction with this Application are incorporated into this Application and
made a part of it.
The undersigned, as your authorized representative or agent, declares to the best of their knowledge and belief and after reasonable
inquiry, that the statements made in this Application are true, accurate, and complete. The undersigned agrees that we will rely on
this Application in issuing any insurance policy providing the requested coverage, and that this Application will form the basis of any
such insurance policy.
NOTICE TO APPLICANTS: 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 ACT, WHICH IS A CRIME AND MAY SUBJECT SUCH PERSON
TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS
A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND
CONFINEMENT IN PRISON.
NOTICE TO COLORADO APPLICANTS: 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 INSURANCE 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 AUTHORITIES.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING
INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON.
PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF
FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.
NOTICE TO FLORIDA APPLICANTS: 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 OF THE THIRD DEGREE.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR
INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
NOTICE TO MAINE APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE INSURANCE COMPANY.
PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.
NOTICE TO MARYLAND APPLICANTS: ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY OR WILLFULLY PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND
CONFINEMENT IN PRISON.
NOTICE TO NEW JERSEY APPLICANTS: ANY PERSON WHO INCLUDES ANY FALSE OR MISLEADING INFORMATION ON
AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS
FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR
DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE,
DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY
CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365:15-1-10, 36
§3613.1).
NOTICE TO OREGON APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR
PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS MATERIALLY FALSE INFORMATION IN AN APPLICATION
FORINSURANCE MAY BE GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.
CSUCRI A0001A CW (05/18)
NOTICE TO PENNSYLVANIA APPLICANTS: 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.
NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE,
INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE
INSURANCE COMPANY. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.
NOTICE TO VERMONT APPLICANTS: 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, MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO CIVIL PENALTIES UNDER
STATE LAW.
NOTICE TO NEW YORK APPLICANTS: 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 ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
Applicant Information:
Applicant Name:
By (Authorized Signature):
Name/Title:
Date:
Producer Information:
Producer Name:
* Producer Signature:
Date:
Address of Producer:
Street:
City: State: Zip:
E-Mail Address:
** Producer License Number:
* required only in the following State(s): Iowa
** required only in the following State(s): Florida
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Hiscox Insurance Company Inc. Executive Risks Crime Application (Special Risks)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 July 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document