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Applicant Information
Business Type Information
Company Name
Contact Name
Email Address
Company Address
City
State
Zip
Are there additional locations? (If Yes, list in Addt'l Comments section)
Phone
Fax
Business Information
Type of Business
Purpose and Function
Have you sustained any employee dishonesty losses in the last 6 years?
If Yes, please give details below
Bond Information
Amount of coverage requested
Term of bond requested
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 a
Exact Numb er 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?
By whom?
How ofter will a complete audit be made?
When was the last audit made?
By whom was audit made?
Are bank accounts reconciled by someone not authorized to deposit or withdraw therefrom?
How often?
Classification 'B'
Businesses with more exposure such as cafes, gas stations, retail stores, businesses with salespeople, non-profit social organizations (officers and e
Contains a conviction clause. to order to protect you and your employes! against unjustified allegations of dishonesty, the employee must be confined
Exact Numb er of Employees (Both full and part-time)
Exact Number of Owners/Officers
Are owners/officers to be covered?
(If 'Yes', coverage of owners/offiers is subject to underwriter approval.)
Additional Comments
Additional Comments