Within the last five years, has any employment related, or third-party discrimination, or third-party harassment inquiry, complaint, notice of hearing, claim or suit been made against any entity proposed for insurance or any person proposed for insurance in the capacity of either director, officer, member (if an LLC), or employee of any entity proposed for insurance? NO
Has the applicant, any subsidiary, or any entity seeking coverage, ever had a policy with United States Liability Insurance Co., Mt. Vernon Fire Insurance Co., U.S. Underwriters Co. or Mt. Vernon Specialty Insurance Co.? NO
How many full-time employees?
How many part-time employees?
How many temporary/seasonal employees?
How many independent contractor employees?
How many leased employees?
Are there employees/independent contractors in California, Florida, Louisiana or outside the U.S.?
Is any person(s) proposed for this Insurance aware of any fact, circumstance or situation which may result in an employment claim, or third-party discrimination, or third-party harassment claim against any entity proposed for Insurance or any of its Directors, Officers, Members (if an LLC), or Employees? NO
PLEASE PROVIDE THE DESIRED LIMITS AND DEDUCTIBLES FOR THE FOLLOWING:
I. Employee Dishonest
II. Forgery or Alteration
III. Inside the Premises
IV. Outside the Premises
V. Computer Fraud
VI. Money Orders & Counterfeit Paper currency
VII. Loss of Clients Property
VIII. Funds Transfer Fraud
* Note standard industry deductibles: are $500, $1000, $2,500, $5,000 & $10,000. Select any of the above insurance coverage agreement sections. TechRisks.com recommends if you have contracts that require crime insurance, Loss of Clients Property would be necessary. Employee Dishonesty and other insurance agreement section largely apply applies to your company losses.
The following statements regarding your insurance application must be true. If not please advise
-
Is there supervision of business activities on a daily business by an owner? Yes. Does that person:
-
Deposit all cash receipts? Yes
-
Reconcile all bank accounts? Yes
-
Sign or countersign all checks? Yes
-
Verify shipping and receiving activities? Yes
-
Check petty cash periodically? Yes
-
Review journal entries? Yes
-
Is segregation of duties performed in the following
-
Inventory management? Yes
-
Oversight of check stock? Yes
-
Vendor Approval? Yes
-
Shipping and receiving? Yes
The following statements regarding your insurance application must be true. If not please advise
-
Are bank accounts reconciled monthly? Yes
-
Are bank accounts reconciled by someone not authorized to deposit, withdrawal or write checks? Yes
-
Are vouchers / supporting records stamped “PAID” when checks are signed? Yes
-
Do you maintain a list of approved vendors? Yes
-
Are systems designed so that no single employee can control a transaction from beginning to end (e.g. approve a voucher, request and sign and check)? Yes
-
Do you screen your employees for prior acts of dishonesty? Yes
-
Are all shipping and receiving activities reconciled to all applicable sale / purchase orders? Yes
-
Do you have system in place to prevent and detect payments to fictitious vendors? Yes
-
Is all purchasing centralized out to maintain your main office? Yes
What is the total amount of specified property for all locations combined:
Cash?
Retail Checks?
Credit Card Receipts?
Do you handle, store or use valuable or precious and or non-precious metals? We assume you do not unless noted here:
Financial Status: Per Last FYE
Total and % Change for prior year
Annual Gross Assets
Annual Gross Sales
Net Profit
Net Worth
The following statements regarding your insurance application must be true. If not please advise
-
Has any similar insurance been declined or cancelled during the past three years? NO
-
Loss History
-
Enter all claims or occurrences that may give rise to claims for the prior 5 years. NONE If Yes, please confirm
-
Date of Occurrence
-
Type / Description of Occurrence or Claims Date of Claim
-
Amount Paid
-
Claim open or Closed?
-
Please email e-contact@techrisk.com corrective actions taken if there is a previous loss history
If you need Directors and Officers Insurance or if you are going through a Merger or Acquisition, please note here.
