Fidelity Insurance Proposal

Full name of proposer

Address

E-mail

Trade or Business

How has the business been established?

Have there been any losses(whether insured or not) due to the dishonesty of Empliyees, partners or directors during the last five years?

YesNo

If 'Yes' please provide details of date, amount and steps taken to prevent recurrence

Has there been any occasion to question the honesty of any present or former Employee during the last five years?

YesNo

If 'Yes' please provide details

Has any insurance in respect of the risks to which this proposal relates

Declined a proposal, refused renewal or cancelled an insurance?

YesNo

Required an increased premium of imposed special conditions?

YesNo

If 'Yes' to the previous two questions, please provide details

Do you always obtain references directly from former employers for the three year's immediately preceding engagement of employees responsible for money, goods Or computer operations

YesNo

Are the references in writing?

YesNo

If 'Yes' to the previous two questions, please provide details

Please state largest amount any employee is responsible for at any one time

MoneyGoods

SYSTEM OF CHECK

1. Do you have an internal audit department?

YesNo

If 'Yes' to whom does the department manager report?

And how frequently are all areas of the business audited?

2. A) Do external auditors examine your accounts every twelve monts?

YesNo

B) Who are the external auditors?

3. Are employees receiving cash cheques in the course of their duties required? to pay in all such monies and / or bank in full on the day of receipt or the next banking day?

YesNo

4. Are bank statements, receipts, counterfoils and supporting documents checked (independently of the employees responsible) at least monthly against the cash book entries and is the balance tested with cash and un presented cheques?

YesNo

5. A)Is there a predetermined limit above which manually prepared cheques or other bank instruments are required to have two signatures?

YesNo

If 'yes', what is the limit?

B) Does one signatory examine the supporting documentation before signing the cheque or instrument?

YesNo

C) 1. In the case of computer of machine produced cheques is the supporting documentation examined before the requisition is input?

YesNo

C) 2. Is there a predetermined limit above which two signatures are required before the requisition for such a cheque is input

YesNo

If 'yes', what is the limit?

6. Is cash in hand and petty cash checked independently of the employees responsible at least weekly?

YesNo

7. Is the wages and salary documentation checked, independently of the employees responsible, before payments are made?

YesNo

8. Is a reconciliation by means of a formal stock-taking process carried out on all stock independently of the employees responsible for such stock?

YesNo

If 'Yes' at what intervals (months)

9. Are different employees, acting independently, responsible for the ordering of stock and materials, the recording of the receipt of such and authorizing the payment of them?

YesNo

10. A) Are statements of account for all amounts due sent to customers by post at least monthly?

YesNo

10. B) is it your practice to ensure that employees who receive cash or cheques cannot interfere with the dispatch of statements of account and reminders of payment?

YesNo

10. C) Is action taken at management level if an account becomes three months overdue?

YesNo

11. Are any of your accounting, salary or stock control functions computerised?

YesNo

If yes, Are responsibilities for authorization of transaction, processing of transactions and handling of output exercised by different employees?

YesNo

Do your internal auditors supervise company security?

YesNo

Do your external auditors examine your computer security?

YesNo

Do you use a "Mainframe" computer (le Not a "Personal Computer")

YesNo

Is access to the systems controlled by password procedures so that only staff with appropriate authority can enter?

YesNo

Do procedures exist to ensure that all changes to programmers are authorized at the appropriate level?

YesNo

Is there an adequate system to check that these procedures have been complied with?

YesNo

Is a log kept showing all changes to programmes

YesNo

SCOPE OF COVER

1. Do you wish to pay the first part of each claim?yesno

If 'Yes', Please state amount

2. Which of the following types of cover do you require?

A) Cover for entire workforceB) Cover for employees in selected categories of occupation onlyC) Cover for named employees only

A) Cover for entire workforce:-

a) Staff with direct responsibility for money, stock accounts or computer operationsb) Other staff

Limit of indemnity required

Number of Employees Estimated Annual Remuneration

Cover for employees in selected categories of occupations only:-

Total Limit of Indemnity required for all employees

Cover for named employees only:-

Total Limit of Indemnity required for all employees

I/We declare that these statements made by me/us or on my/our behalf are to the best of my/our knowledge and belief true and complete and shall be incorporated in the contract between me/us and the company. I/We agree to accept a policy in the Company's usual form for this class of insurance.

Name:

Date:

Signing this form does not oblige you to complete the insurance

Category: