CrimeInsurance Application Company Name * Website * http:// Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Primary Contact * First Name Last Name Email * HR Contact * First Name Last Name Email * How many full-time employees do you have? * How many part-time? * How many contractors or seasonal? * How many employees or contractors are in California? * Have there been any leadership changes in last 3 years (other than retirement/death)? * Yes No In the past 12 months, any closures/mergers/consolidations causing 20%+ layoffs (or planned)? * Yes No Public offerings or private placements in last 24 months (or planned)? * Yes No Reorganization/arrangement with creditors in last 24 months (or planned)? * Yes No Mergers, acquisitions, or divestitures in last 24 months (or planned)? * Yes No Are all bank accounts formally reconciled each month? * Yes No Are duties segregated so that no single employee can request, approve, and issue payments? * Yes No Are invoices matched to confirmed receipt of goods or services before payment is released? * Yes No Is a countersignature required for checks exceeding $25,000? * Yes No Is a physical inventory taken at least annually and reconciled with company records? * Yes No Does the company have custody or control of client funds, accounts, or materials? * Yes No Has the company or any proposed insured sustained a crime-related loss in the past 3 years? * Yes No Are secondary communication methods used to confirm authenticity of funds transfer requests (ACH, wire, etc.) exceeding $25,000? * Yes No Do you have existing Directors & Officers (D&O) coverage? * Yes No Do you have existing Employment Practices Liability (EPL) coverage? * Yes No Do you have existing Fiduciary Liability coverage? * Yes No Do you have existing Cyber Liability coverage? * Yes No Do you have existing Tech Errors & Omissions (E&O) coverage? * Yes No Total Revenue (most recent FY end) * $ Total Assets (most recent FY end) * $ Total Liabilities (most recent FY end) * $ Net Income (most recent FY end) * $ Total Cash (most recent FY end) * $ Prior knowledge of any facts/circumstances that could reasonably give rise to a claim? * Yes No What percentage of customer agreements are standard form vs. manuscript? (Best estimate.) * 0-25% 26-50% 51-75% 76-100% Thank you - your application has been submitted. An Execurisk broker will contact you within 24 hours. In the meanwhile, please send your financial documents to docs@execurisk.com.
