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Dishonesty Bond Web ApplicationFidelity surety bond


Applicant:
Type of Business:
Purpose and function:
Classification of Business *A or B coverage subject to underwriter discretion.
Name of Business:
Address (include any branch location):
Street Address:
City:
State:
Zip Code:
Business Phone:
Business Fax:
Email Address:
We will email your new bond directly to this email address upon request, usually within 1 business day.
Have you sustained any employee dishonesty losses in the last 6 years?
 Yes
 No
If so, please give us all the details below.
 A
Amount of coverage requested:
 $5,000
 $10,000
 $25,000
 $50,000
 $100,000
Professional and business offices such as accountants, architects,
Are officers to be covered?
 Yes
 No
Exact Number of Officers
Term Requested:
 1-Year Bond
 3-Year Bond
 reduced rate of 2.85 x annual premium)
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):
 Certified Public Accountant
 Independent Accountant
 Employee of Insured
Exact Number of Officers:
Referred By:
**In order to protect you and your employees against unjustified allegations of dishonesty, the employee must be convicted before coverage will apply.
Additional Information
 A
For Dishonesty A limits $50,000 and over, please complete the following:
***Coverage of owners/officers is subject to underwriter approval.
Non-Profit Social Organizations - Officers Only
Will countersignature of checks be required?
 Yes
 No
Exact Number of Officers:
By whom?
List of Officer Positions
How often will a complete audit be made?
 Pay With Credit Card (6%on line fee added)
***Coverage of officers is subject to underwriter approval.
When was last audit made?
Are officers to be covered?
 Yes
 No
(Required to receive bond via email.). *
By whom was audit made?
Are bank accounts reconciled by someone not authorized to deposit or withdraw there from?
 Yes
 No
How often?
Credit Card Name:
 B
Credit Card Billing Address: (If different from above)
Street Address
Businesses with more exposure such as cafes, gas stations, retail stores, businesses with salespeople, non-profit social organizations (officers and employees - Note: Volunteers not covered unless endorsement added by Company) and courier services (except
City:
State:
Exact Number of Employees (Both full and part-time)
Zip:
VISA or Master Card Account Number
Expiration Date:
3 Digit Security Code
For Appointed Brokers*
Broker Code
Broker Name
*need filled in to receive commission
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