Business Information

Type of Business Purpose and Function Have you sustained any employee dishonesty losses in the last 6 years? Yes   No         If "Yes", please give details below:

 

Bond Information

Amount of coverage requested Term of bond requested - Select One - $5,000 $10,000 $25,000 $50,000 $100,000 1-Year Bond     3-Year Bond* (* reduced rate of 2.85 x annual premium)

 

Classification of Business

A or B coverage subject to underwriter discretion

Classification "A"  Professional and business offices such as accountants, architects, physicians, non-propfit social organizations (officers only), dentists, insurance agents, and attorneys. (Owners/officers are not covered under this bond, unless the insured is a corporation, and the owners/officers are in the regular service of the insured and compensated by salary, wages, etc.) Exact Number of Employees   (Both full and part-time) For Dishonesty A limits $50,000 and over, please complete the following: Will countersignature of checks be required? Yes   No By whom? How ofter will a complete audit be made? When was the last audit made? By whom was audit made? - Select One - Certified Public Accountant Independent Accountant Employee of Insured Are bank accounts reconciled by someone not authorized to deposit or withdraw therefrom? Yes   No How often?

Classification "B"  Businesses with more exposure such as cafes, gas stations, retail stores, businesses with salespeople, non-profit social organizations (officers and employees) and courier services (except those handling cash and negotiable instruments). Contains a conviction clause. In order to protect you and your employees against unjustified allegations of dishonesty, the employee must be convicted before coverage will apply. Exact Number of Employees   (Both full and part-time) Exact Number of Owners/Officers   Are owners/officers to be covered?   Yes     No   (If "Yes", coverage of owners/officers is subject to   underwriter approval.)

 

Additional Comments

Please provide any additional comments you may have in regards to this Bond Application, or list any additional information that you did not have room for in the data fields above.

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