Name of Applicant/Business/Organization *

Type of Business or Organization * Sole Proprietorship  Partnership  Corporation  LLC  LLP  Non-Profit

Member # / Agency Customer ID (if applicable) 

Email Address *    Daytime Phone # *

Physical Address *

City *     State * Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip *

Mailing Address 

City     State Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip 

Type of Business & Function *

Have you sustained any employee dishonesty losses in the last 6 years? * Yes  No   If Yes, please provide the details in a letter.

Amount of coverage requested * $5,000  $10,000  $25,000  $50,000  $100,000  $125,000  $150,000  $175,000  $200,000

    Note:  Limits above $100,000 not available in CA, TX, and VA.

Bond Term * 1-Year Bond  3-Year Bond (reduced rate of 2.85 x annual premium) (TX - 3-Year term only available for Dishonesty B)

Dishonesty A for Professional and Business Offices

Includes accountants, architects, physicians, dentists, insurance agents, attorneys and similar-type professionals. (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, wages, etc.)   

Exact Number of Employees (Both full and part-time)

Exact Number of Officers

Are officers to be covered?   Yes***  No

For Texas, include a list of officer titles.  For Texas, Dishonesty A coverage is written as Commercial Blanket.

 

Dishonesty A for Non-Profit Social Organizations

When covering Officers - tell us how many and titles below.

When covering Employees + Officers - also complete Dishonesty B below.

When covering Employees only - skip to complete Dishonesty B below.

Exact Number of Officers

                                       Officer Positions

Title     

Title     

Title     

Title

Title

Title

 

For Dishonesty A limits $100,000 and over, please complete the following:

Will countersignature of checks be required?  Yes  No

How often will a complete audit be made?

When was last audit made?

By whom was audit made?

Certified Public Accountant  Independent Accountant  Other

Are bank accounts reconciled by someone not authorized to deposit or withdraw there from (separation of duties)?   Yes  No

How often?

Dishonesty B for Retails, For-Profit, and All Other Businesses **

Businesses with more exposure such as cafes, gas stations, retail stores, businesses with salespeople, home/condo owner associations, non-profit social organizations (officers and employees) and courier services (except those handling cash and negotiable instruments).  Note: Independent contractors and volunteers are not covered unless endorsement is added by the surety.  Contains a conviction clause. 

Exact Number of Employees (Both full and part-time)

Exact Number of Owners/Officers (Provide officer positions below)

Are officers to be covered?   Yes***  No

                   Officer Positions (HOA/Condo Association Only)

Title     

Title     

Title     

Title

Title

Title

Date (mm/dd/yyyy) *

The effective date of the bond will be the date the bond is issued or future date by request.

*A or B coverage subject to underwriter discretion.
**In order to protect you and your employees against unjustified allegations of dishonesty, the employee must be convicted before coverage will apply.
***Coverage of officers is subject to underwriter approval.