| Have
you sustained any employee dishonesty losses in the last 6 years?
Yes / No |
| Amount of coverage
requested: |
Classification of Business
Professional
& Business offices such as accountants, architects, physicians, dentists,
insurance agents, and attorneys. (Officers are not covered
under this bond, unless the insured is a corporation, and the officers
are in the regular service of the insured and compensated by salary, wage,
etc). |
Exact # of Employees (both
full & parttime):
Exact # of Officers....................................:
Are officers to be covered?
Yes / No |
| Non-Profit
Social Organizations (OFFICERS ONLY) |
Exact # of Officers: |
| Businesses
with more exposure such as cafes, gas stations, retail stores, businesses
with salespeople, non-profit social organizations (officers & employees:
volunteers are not covered unless endorsed by the insurance company) and
courier services (except those handling cash & negotiable instruments
). |
Exact # of Employees (both
full & parttime):
Exact # of Owners/Officers........................:
Are officers to be covered?
Yes / No |
| For dishonesty limits $ 50,000 and Over,
please complete the following: |
Will Countersignature
of checks be required?
Yes /
No
If
"Yes", by whom: |
| How often will
a complete audit be made?
Last Audit was made: (date) |
| Who made the
last audit:
CPA /
Independent Accountant /
Employee of Insured |
| Are bank accounts
reconciled by someone not authorized to deposit or withdraw from them?
Yes / No |
