Crime Application
Company Name
Street Address, Include Floor #
City
State
Zip
Tel #
Contact Name
Contact Title
Contact Tel#
Contact e-mail
Website (if any)
Tyep of Business
Number of Locations
Deductible Requested
What type of work do you perform for clients?
How many employees will be on the premises of your clients?
Will you have access to clients’ money, securities, banking systems, wire transfer systems, or any sensitive computer data?
Will you have restriced access to physical area of clients’ premises by keycards, locks, etc?
Will you be performing your services during normal business hours (ie 9am - 5pm)
Will your employees be supervised and/or monitored by your clients when performing services on their premises?
Yes
No
Will your employees be required to wear ID badges or carry special IDs in order to identify themselves as non-employees?
Yes
No
Do you perform background checks on your employees, including person references, past employments references, criminal records, drug testing?
Yes
No
If no, please explain.
Do you have any knowledge of an employee stealing from a client that may give rise to claims in the prior 5 years?
Yes
No
If yes, please provide details, including description of the loss, amount of the loss, and corrective action taken.
