For Help Call 412-372-4300 |
|
Fields marked (*) are mandatory. |
|
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 | |