Crime Insurance Intake

I. GENERAL INFORMATION

Applicant Information

Name of Applicant

Applicant's Email *

Address

Street Address
City, State, ZIP Code

Website Address

Year Applicant’s business was established:

Description of Applicant’s operations:

Applicant’s Standard Industrial Classification (SIC) code, if known (4-digit number):

II. PROPOSED ADDITIONAL INSUREDS (OTHER THAN APPLICANT)*

Complete the following table indicating all additional entities for which coverage is requested:

Name of Entity

Description of Operations and Relationship to Applicant

Name of 2nd Entity

2nd Description of Operations and Relationship to Applicant

Name of 3rd Entity

3rd Description of Operations and Relationship to Applicant

To enter more information, please attach a separate page or an organization chart.

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IMPORTANT NOTE: Receipt of this information does not constitute an agreement that coverage will be provided to the listed entities.

III. EMPLOYEE**/LOCATION/EXPOSURE INFORMATION

Number of employees** at all locations:

Total number of volunteers (only if Applicant is qualified as a non-profit organization):

Total number of locations:

Number of locations outside the United States:

If there are locations outside the United States, indicate domicile of each here

Number of employees** outside the United States:

** Employee count should include full time, part time, leased, temporary and seasonal workers.

Indicate the total amount of specified property INSIDE the premises for all locations combined:

Cash

Retail Checks***

*** Retail Checks are only those checks that are accepted as immediate payment for retail products or services.

Credit Card ecReipts

Indicate the total amount of specified property being transported by a messenger OUTSIDE the premises for all locations combined:

Cash

Retail Checks***

*** Retail Checks are only those checks that are accepted as immediate payment for retail products or services.

Credit Card ecReipts

IV. FINANCIAL INFORMATION

In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has the Applicant completed or been in the process of) any reorganization or arrangement with creditors under federal or state law?

Yes
No

If Yes, please write an explanation with full details of the circumstances of such an event.

Indicate the following as it relates to the Applicant’s fiscal year end (FYE): (Please indicate negative figures with “( )” or “-” as appropriate)
Total Assets

Most Recent FYE (Month/Year)

Prior FYE (Month/Year)

Retained Earnings (Accumulated Deficit/Fund Deficit)

Most Recent FYE (Month/Year)

Prior FYE (Month/Year)

Net Equity/Net Assets (Deficit Equity)

Most Recent FYE (Month/Year)

Prior FYE (Month/Year)

Revenues

Most Recent FYE (Month/Year)

Prior FYE (Month/Year)

Net Income (Net Loss)

Most Recent FYE (Month/Year)

Prior FYE (Month/Year)

V. AUDITOR INFORMATION

Scope of financial statement preparation:

Have the outside auditors stated there are material weaknesses in the Applicant’s systems of internal controls?

N/A
Yes
No

If Yes, please provide an explanation and provide the latest CPA letter to management and management’s response.

Has the applicant implemented all material recommendations of the auditor?

N/A
Yes
No

If No, please provide an explanation.

Has any auditor issued a “going concern” opinion for the Applicant’s financial statements during the past 3 years?

N/A
Yes
No

If Yes, please provide an explanation.

Does the Applicant maintain an internal audit department?

Yes
No

If Yes, how many individuals are in the internal audit department?

VI. INTERNAL CONTROLS

Are bank account statements reconciled at least monthly?

Yes
No

Does someone other than the person responsible for reconciling bank accounts:

Is countersignature of checks required?

Yes
No

If Yes, what is the dual signing limit?

Is segregation of duties practiced in the following areas:

Are all incoming checks stamped “for deposit only” immediately upon receipt?

Yes
No

Are deposits of cash and checks made at least daily?

Yes
No

Is a physical count of inventory conducted at least annually?

Yes
No

Do you conduct periodic reviews of all unused or obsolete inventory (including raw materials and scrap metals)?

N/A
Yes
No

Are inventory records computerized?

Yes
No

Are the same internal controls listed above imposed on all locations and entities?

Yes
No

VII. COMPUTER AND FUNDS TRANSFER CONTROLS

Is there a software security system in place to detect fraudulent computer usage by employees, agents and outsiders?

Yes
No

Are passwords and access codes changed at regular intervals and when users are terminated?

Yes
No

Are computer programmers permitted to use machines with programs they have written?

Yes
No

Are computer check writing functions separate from check authorization?

Yes
No

Are EDP systems, programs, and procedures, including changes there to, authorized, documented and tested?

Yes
No

Is there physical and functional segregation of personnel and periodic job shifts or job rotations?

Yes
No

Is dual authorization required for all wire transfers?

N/A
Yes
No

What is the average daily dollar volume of electronic funds transfers?

Ignore if not applicable

Are transfer verifications sent to an employee or department other than the one that initiated the transfer?

Yes
No

VIII. BUSINESS PRACTICES AND PHYSICAL CONTROLS

Indicate if you have or perform any of the following (check all that apply):

IX. UNIQUE/SIGNIFICANT EXPOSURES

Indicate any of the following characteristics or exposures that apply to your business operations (check all that apply):

If you checked any of the characteristics or exposures above, please provide details that quantify the exposure and briefly describe the controls in place to protect you from loss in a separate attachment.

X. CURRENT INSURANCE INFORMATION/REQUESTED INSURANCE TERMS

Desired Crime Coverage

Fidelity: Employee Theft

Requested Limit

Requested Retention

Fidelity: ERISA Fidelity

Requested Limit

Requested Retention

Fidelity: Employee Theft of Client Property

Requested Limit

Requested Retention

Forgery or Alteration

Requested Limit

Requested Retention

On Premises (Money, Securities and Other Property)

Requested Limit

Requested Retention

In Transit (Money, Securities and Other Property)

Requested Limit

Requested Retention

Money Orders and Counterfeit Money

Requested Limit

Requested Retention

Computer Crime

Requested Limit

Requested Retention

Funds Transfer Fraud

Requested Limit

Requested Retention

Personal Accounts Protection

Requested Limit

Requested Retention

Claim Expense

Requested Limit

Requested Retention

Expiring insurer:

a Layout periodic

Expiring premium:

XI. LOSS INFORMATION

Has the Applicant or any proposed insured sustained any crime-related losses in the past 3 years?

Yes
No

If Yes, please provide: Date of Loss, Amount of Loss, Description of Loss, and Corrective Procedures Implemented

XII. REQUIRED ATTACHMENTS

As part of this Application, please submit the following documents:

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- Most recent annual financial statement, for limit requests of $5,000,000 or greater
- CPA Management Letter, if prepared, as well as management’s response thereto, for limit requests of $5,000,000 or greater
- If coverage for Employee Theft of Client Property (Third Party Crime) is requested, submit separate Third Party Crime Application

service@monteleoneins.com | 631-544-4000

I. GENERAL INFORMATION

II. PROPOSED ADDITIONAL INSUREDS (OTHER THAN APPLICANT)*

III. EMPLOYEE**/LOCATION/EXPOSURE INFORMATION

IV. FINANCIAL INFORMATION

V. AUDITOR INFORMATION

VI. INTERNAL CONTROLS

VII. COMPUTER AND FUNDS TRANSFER CONTROLS

VIII. BUSINESS PRACTICES AND PHYSICAL CONTROLS

IX. UNIQUE/SIGNIFICANT EXPOSURES

X. CURRENT INSURANCE INFORMATION/REQUESTED INSURANCE TERMS

Desired Crime Coverage

In Transit (Money, Securities and Other Property)

XI. LOSS INFORMATION

XII. REQUIRED ATTACHMENTS

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