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CRIME PLUS+ POLICY

Travelers Property Casualty

A member of Travelers Group

NAVREF Program Application (Limits of more than $1 million )
 

Name

  _______________________________

SIC code

 ________

Agent

 P. Allen Haney Co,

(If more than one Insured, please attach a list)

  

Agent Code

 053-3200
 
Address ______________________________________________________________________________________

______________________________________________________________________________________
City __________________

State

 _________

Zip

 ________ Effective Date ___________________
 

Predominant Business Activity

 __________________________________ Billing ___________________

Year Business Started

 _________

Annual Sales or Revenue

 ________

Installment

Prepaid
 
Are you a publicly traded company? Yes No If yes, ticker symbol ____________________________________
 

 

Desired Coverage Limits of Liability
If all six basic Insuring Agreements are desired at the same Limit: ________________________________
or, if varying Limits or Insuring Agreements are desired: ________________________________
Insuring Agreement I: Employee Dishonesty ________________________________
Insuring Agreement II: Forgery and Alteration ________________________________
Insuring Agreement III: On Premises ________________________________
Insuring Agreement IV: In Transit ________________________________
Insuring Agreement V: Money Orders and Counterfeit Paper Currency ________________________________
Insuring Agreement VI: Computer Fraud and Funds Transfer fraud ________________________________
Other: ________________________________
Deductibles:
Prior Insurer:_________ Limit:_________ Deductible:_________ Premium: _________
Loss Experience:

List all crime losses sustained during the last three years whether reimbursed or not. Check here if none

Date of Loss Total Amount of Loss Description of Loss and Corrective Action
______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Number of Employees*

US/Canada

Other Countries

Total
 
Locations (other than main office) ______________   ______________   ______________
 
*Also includes the following: Leased ______________ Temporary ______________ and Non-compensated Employees ______________
 

 

Companies that practice segregation of duties and perform background checks on new employees have a better opportunity to either prevent or detect employee dishonesty. Segregation of duties means that no single employee can control a process or transaction from beginning to end.

1.  Do employees who reconcile the bank statement also:
Make deposits: Yes No Make withdrawals Yes No
Sign checks? Yes No  
2.  Is segregation of duties practiced in the following areas:
Inventory? Yes No Purchasing? Yes No
Payroll? Yes No Disbursements? Yes No

F-3191 (7/97)

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last updated: 01/04/10

 

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