Fillable Social Eng Fraud Application (CSRisks)

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Social Eng Fraud Application (CSRisks)

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Social Engineering Fraud Coverage
Supplemental Application
*To be able to save this form after the elds are lled in, you will need to have Adobe Reader 9 or later. If you do not have
version 9 or later, please download the free tool at: http://get.adobe.com/reader/.
Carrier Name: ________________________________
THE LIABILITY POLICY THAT MAY BE ISSUED BASED UPON THIS APPLICATION PROVIDES CLAIMS MADE
COVERAGE WRITTEN ON A NO DUTY TO DEFEND BASIS. DEFENSE COSTS ARE INCLUDED WITHIN THE LIMIT OF
LIABILITY AND REDUCE THE LIMIT OF LIABILITY AVAILABLE TO PAY SETTLEMENTS AND JUDGMENTS. PLEASE
READ THE POLICY CAREFULLY.
Applicant (Parent Company): __________________________________________________________________________________________
Address: _________________________________________ City: _________________ State: ____________ Zip Code: ______________
P.O. Box: _________________________________________ City: _________________ State: ____________ Zip Code: ______________
Telephone: ________________________________________ Website: ________________________________________________________
Representative authorized to receive notices on behalf of the applicant and all subsidiaries:
Name: ___________________________________________ Title: ___________________________ Email: __________________________
1. Does the Applicant accept funds transfer instructions from customers over the telephone, email,
text message or similar method of communication?
Yes
No
If yes, please describe the communication methods by which such instructions are received:
2. Does the Applicant conrm all funds transfer instructions from a customer by a direct call to the customer
using only the telephone number provided by the customer prior to the funds transfer instruction was received?
Yes
No
Section 1 – General Information
Section II – Vendor Controls
Section III – Customer Controls
Page 1 of 3
1. Does the Applicant have procedures in place to verify the authenticity of invoices and other payment
requests received from a vendor?
Yes
No
2. Does the Applicant have procedures in place to verify the receipt of inventory, supplies, goods or
services against an invoice prior to making a payment to a vendor?
Yes
No
3. When a vendor requests any changes to its account details (including, but not limited to,
bank routing numbers, account numbers, telephone numbers, or contact information), does the Applicant:
a) Conrm all change requests by a direct call to the vendor using only a contact number
provided by the vendor before the request was received?
Yes
No
b) conrm all change requests with someone at the vendor, other than the person who sent the
request, before making the change?
Yes
No
c) refrain from making any change requests until after the vendor has responded to the
Applicant’s inquiry regarding change request authenticity?
Yes
No
Section IV – Internal Transfer Controls
Page 2 of 3
1. Who in the Applicant’s organization has the authority to initiate ACH or wire transfers? ___________________________________
2. Can ACH or wire transfer authority be delegated to anyone verbally or in writing within the
Applicant’s organization?
Yes
No
3. Does the Applicant have a call back procedure in place to verify any ACH or wire transfer
request received from another employee, location, or department of the Applicant?
Yes
No
4. Do ACH or wire transfer requests of a certain amount require approval by two or more of the
Applicant’s employees?
Yes
No
If yes, what is the amount? $ _____________________
5. Does the Applicant provide guidance and periodic anti-fraud training to employees concerning the
detection of phishing and other social engineering scams?
Yes
No
If yes, what is the amount? $ _____________________
Section V – Loss Experience
1. Within the past 3 years, has the Applicant received any fraudulent emails, purportedly from customers,
vendors, or employees seeking to direct transfers of the Applicant’s funds?
Yes
No
If yes, please provide a brief summary of each incident, date of loss, total amount of loss and
any corrective action:
Fraud Warning
Any person who knowingly and with intent to defraud any insurance company or another person les 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 may be a crime and may subject the
person to criminal penalties.
ALABAMA, ARKANSAS, LOUISIANA, NEW JERSEY, NEW MEXICO, RHODE ISLAND, VIRGINIA and WEST VIRGINIA: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benet or knowingly presents false information in an Application for insurance is guilty of a crime. In Alabama, Arkansas, Louisiana, Rhode
Island and West Virginia that person may be subject to nes, imprisonment or both. In New Mexico, that person may be subject to civil nes and criminal penalties. In Virginia, penalties
may include imprisonment, nes and denial of insurance benets.
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, nes, 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.
DISTRICT OF COLUMBIA, KENTUCKY and PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person les an Application
for insurance or statement of claim containing 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. In District of Columbia, penalties include imprisonment and/or nes. In addition, the Insurer may deny insurance benets if the Applicant
provides false information materially related to a claim. In Pennsylvania, the person may also be subject to criminal and civil penalties.
FLORIDA and OKLAHOMA: Any person who knowingly and with intent to injure, defraud or deceive the Insurer, les a statement of claim or an Application containing any false,
incomplete or misleading information is guilty of a felony. In Florida it is a felony to the third degree.
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 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 benet pursuant to an insurance policy for personal or commercial 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 is considered a crime.
MAINE: 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, nes or denial of insurance benets.
MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benet or knowingly or willfully presents false information in an
Application for insurance is guilty of a crime and may be subject to nes and connement in prison.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against the Insurer, submits an Application or les a claim containing a false or deceptive
statement is guilty of insurance fraud.
OREGON: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly presents false information in an application for insurance may be
guilty of a crime and may be subject to nes and connement in prison.
TENNESSEE 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, nes and/or denial of insurance benets.
800 Superior Avenue E., 21st Floor • Cleveland, OH 44114 • Phone: 866.327.6904 • Fax: 216.328.6251 • www.amtrust.com
Submit applications to: banksubmissions@amtrustgroup.com
Representation Statement
The undersigned declare that, to the best of their knowledge and belief, the statements in this Application, any prior Applications, any additional material submitted, and any publicly
available information published or led by or with a recognized source, agency or institution regarding business information for the Applicant for the 3 years prior to the Bond/
Policy’s inception [hereinafter called “Application”] are true, accurate and complete, and that reasonable efforts have been made to obtain sufcient information from each and every
individual or entity proposed for this insurance. It is further agreed by the Applicant that the statements in this Application are their representations, they are material and that the
Bond/Policy is issued in reliance upon the truth of such representations.
The signing of this Application does not bind the undersigned to purchase the insurance and accepting this Application does not bind the Insurer to complete the insurance or
to issue any particular Bond/Policy. If a Bond/Policy is issued, it is understood and agreed that the Insurer relied upon this Application in issuing each such Bond/Policy and any
Endorsements thereto. The undersigned further agrees that if the statements in this Application change before the effective date of any proposed Bond/Policy, which would render
this Application inaccurate or incomplete, notice of such change will be reported in writing to the Insurer immediately.
Page 3 of 3
MKT5074 3/16
Submit Application to:
banksubmissions@amtrustgroup.com
AmTrust North America
Attention: Financial Institution Division
800 Superior Avenue E., 21st Floor • Cleveland, OH, 44114
Phone: 866.327.6904 • Fax: 216.328.6251
www.amtrus.com
Chief Executive Ofcer, President or Chairman of the Board:
Print Name: _________________________________________________ Signature: ____________________________________________
Title: _______________________________________________________ Date: ________________________________________________
Policy cannot be issued unless the application is signed and dated by an authorized representative:
Agent Name: _______________________________________________
Agent Signature: ____________________________________________ License Number: ______________________________________
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Social Eng Fraud Application (CSRisks)

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Completed 16 July 2020

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