ACORD CRIME SECTION - advancede-s.com

1 CRIME SECTIONABCDEFGHQPLAN 1 COVERAGE AMENDMENTS (Endorsements)ERISA EMPLOYEE DISHONESTY - ADDITIONAL INFORMATION (Coverage Form A)CLASSIFICATION OF EMPLOYEES/LOCATIONS (Coverage Forms A & B)CONTROLS (Coverage Form A) ACORD 141 (10/98)cOACORD CORPORATION 1980 ATTACH TO APPLICANT INFORMATION SECTIONDATEPRODUCERPHONE(A/C, No, Ext):CODE:SUB CODE:AGENCYCUSTOMER ID:APPLICANT(FirstNamedInsured)EFFECTIVE DATEEXPIRATION DATEPAYMENT PLANAUDITFORCOMPANYUSE ONLYBASIS FOR COVERAGEDISCOVERYLOSS SUSTAINEDFORM TITLELIMITDEDUCTIBLEFORM TITLELIMITDEDUCTIBLE$$$$$$$$$$$$$$$NAME OF PLANPRINCIPAL ADDRESSNUMBER OF TRUSTEES,EMPLOYEES, ETCHANDLING PLAN ASSETSNUMBER OFPLAN PARTICIPANTSNUMBER OF:NUMBER OF:NUMBER OF:NUMBER OF:NUMBER OFOFFICERS:TOTAL NUMBER OFOTHER EMPLOYEES:MANUFACTURERS, PROCESSORS, WHOLESALERSOR DISTRIBUTORS; NUMBER OF RETAIL LOCATIONS:ALL OTHER CLASSES; NUMBER OF LOCA-TIONS OTHER THAN HOME OR HEAD OFFICES:AUDITBANKING/OTHERYESNOFORMLTRFO RMLTR1. IS THERE AN AUDIT BY?

2 2. AUDIT FREQUENCY?3. DOES AUDIT INCLUDE INVENTORY?4. AUDIT REPORT IS RENDERED TO:5. ARE BANK ACCOUNTS RECONCILED BY SOMEONE NOT AUTHORIZEDTO DEPOSIT OR WITHDRAW?6. IS COUNTERSIGNATURE OF CHECKS REQUIRED?IF NOT, WHO SIGNS CONTROLS?7. WILL SECURITIES BE SUBJECT TO JOINT CONTROL OF TWO OR MORERESPONSIBLE EMPLOYEES?8. ARE ALL OFFICERS AND EMPLOYEES REQUIRED TO TAKE ANNUALVACATIONS OF AT LEAST FIVE CONSECUTIVE BUSINESS DAYS?LIST ALL OFFICERS AND EMPLOYEES (Including those construed to be employees by endorsement), OTHER THAN AGENTS AND PARTNERS,WHO HANDLE OR HAVE CUSTODY OF MONEY, SECURITIES OR OTHER PROPERTY, INCLUDING, IN ANY EVENT, THE POSITIONS LISTED BELOW:DIRECT BILLAGENCY BILLEMPLOYEE DISHONESTYBLANKETSCHEDULEERISATOTAL ASSET VALUE$FORGERY OR ALTERATIONTHEFT, DISAPPEARANCE & DESTRUCTIONSEC 1 - INSIDE THE PREMISESSEC 2 - OUTSIDE THE PREMISESBLANKETSCHEDULEROBBERY & SAFE BURGLARYSEC 1 - INSIDE: ROBBERY OF CUSTOD NSSAFE BURGLARYSEC 2 - OUTSIDE THE PREMISESBLANKETSCHEDULEPREMISES BURGLARYBLANKETSCHEDULECOMPUTER FRAUDEXTORTION(Ins Loss Participation%)PREMISES THEFT & ROBBERY OUTSIDESEC 1 - THEFTSEC 2 - ROBBERY OUTSIDEBLANKETSCHEDULEROBBERY & SAFE BURGLARYMONEY & SECURITIESSEC 1 - INSIDE THE PREMISESSEC 2 - OUTSIDE THE PREMISESBLANKETSCHEDULEIS THERE A LICENSED SECURITIES FIRM RESPONSIBLE FOR INVESTING OF FUNDS UNDER PLAN(S)?

3 YESNOACCOUNTANTS AND ASSTSADJUSTERSADMINISTRATORS AND ASSTSAPPRAISERSAND CLERKS ACTING AS APPRAISERSATTORNEYSAUDITORS AND ASSTSBOOKKEEPERSBUS DRIVERSBUYERS AND ASSTSCANVASSERS (Door-to-door salespeople)CASHIERS AND ASSTSCHAIRPERSONSCHEFS WHO ORDER FOODCOLLECTORSCOMPUTER PROGRAMMERSCOMPTROLLERS AND ASSTSCREDIT CLERKS AND MANAGERSCUSTODIANSDELIVERY PERSONSDEMONSTRATORSDIETITIANS WHO ORDER FOODDRIVERS AND DRIVERS HELPERSFOOD INSPECTORSHEAD PHARMACISTSINSTRUCTORS HAVINGCUSTODY OF MONEY OR SECURITIESJANITORSLOCKER ROOM ATTENDANTSMAITRE D S AND ASSTSMANAGERS AND ASSTSMEDICAL DIRECTORSMESSENGERS, OUTSIDEPAYROLL DISTRIBUTORSPURCHASING AGENTS AND ASSTSRECEIVING CLERKSREFINERY GAUGERS OF OIL COMPANIESHANDLING REFINED GASOLINE AND OILSSALESPEOPLESECURITY PERSONNELSERVICE STATION ATTENDANTSSHIPPING CLERKSSTOCK CLERKSSTOREKEEPERSSTOREROOM PERSONNELSUPERINTENDENTS AND ASSTSSUPERVISORS AND ASSTSTAXI DRIVERSTEACHERS HAVINGCUSTODY OF MONEY OR SECURITIESTIMEKEEPERS AND ASSTSTRUCK DRIVERSWAREHOUSE PERSONNELWINE CELLAR PERSONNELWINE STEWARDS/ESSESALL OTHER OFFICERS ANDEMPLOYEES NOT LISTED ABOVECPAPUBLIC ACCOUNTANTSTAFFOTHER:ANNUALSEMI-ANNUALQU ARTERLYOTHER.

4 YESNOOWNERPARTNERSBOARD OF DIRECTORSOTHER:ACORDTMMONEY - SECURITIES (Coverages Forms C or Q - Blanket Coverage, By Locations)PROPERTY (Coverage Forms D, E, & H)GENERAL INFORMATION (All Coverage Forms Except A & B)SAFE/VAULT (Coverage Forms C, D & Q)MESSENGER PROTECTION (Coverage Forms C, D & Q)PREMISES/SAFE PROTECTION (Coverage Forms C, D, E & H)AUDIT PROCEDURES - SAA COMMERCIAL CRIME POLICYINTERNAL CONTROLS OTHER THAN AUDIT PROCEDURES - SAA COMMERCIALREMARKSUSE ADDITIONAL FORMS IF MORE THAN ONE LOCATIONACORD 141 (10/98)TYPEMONEYCHECKS FORDEPOSITCHECKS FORACCOUNTS PAYABLEPAYROLLCHECKSMONEYOVERNIGHTSECURI TIES(IN BANK/SAFE DEPOSIT)DESCRIPTION OF PROPERTY, MERCHANDISE, STOCK, ETCMAXIMUM VALUEBUSINESS HOURSAVG #EMPLOYEESON DUTYCHECKSSTAMPED FORDEPOSIT ONLYFREQUENCYOFDEPOSITSNIGHTDEPOSITORYUS EDANNUAL GROSS SALESOR RECEIPTS FORLAST FISCAL YEARDOES PREMISESHAVE DOUBLE CYL-INDER DOOR LOCKS?YESNOOTHER INFORMATIONMANUFACTURERLABELCLASSDOOR TYPEROUNDSQUARECOMBINATION LOCKSOUTERINNERCHESTTHICKNESSDOORWALLMES S GR## OF GUARDSPER MESSENGERPRIVATECONVEYANCEUSED?

5 SAFETYSATCHELUSED?MESS GR## OF GUARDSPER MESSENGERPRIVATECONVEYANCEUSED?SAFETYSAT CHELUSED?ENTER THE EXPOSURES FOR EACH CATEGORY. AMOUNTS ENTERED SHOULD BE MAXIMUM #1 MESSENGER #2$$$$$$$$$$$$$$$$ULSMNAULSMNA(EXCL BOLTWORK)YESNOYESNOYESNOYESNOALARM TYPEALARM DESCRIPTIONGRADEEXTENT OF PROTECTIONSAFE/VAULTPREMISESALARM INSTALLED AND SERVICED BY# GUARDS# WATCHPERSONSWATCHPERSONSCERTIFICATE NUMBEREXPIRATION DATE:ACCESSIBLE OPENINGS & PROTECTIONOTHER PROTECTION (Fences, Floodlights, etc)HOLD-UPPREMISESSAFELOCAL GONGCENTRAL STATIONPOLICE CONNECTWITH KEYS123 RPT/CENT STCLOCK HRLYDON T SIGNALPARTIALCOMPLETEYESNOYESNO1. AUDIT BY CPA, PUBLIC ACCOUNTANT OR EQUIVALENT, INDEPENDENT OFYOUR ORGANIZATION?QUARTERLYSEMI-ANNUALLYANNUA LLYNONE2. NAME AND ADDRESS OF PERSON OR FIRM PERFORMING AUDIT3. ALL LOCATIONS AUDITED?4. IS AUDIT MADE IN ACCORDANCE WITH GENERALLY ACCEPTED AUDITINGSTANDARDS AND SO CERTIFIED? IF NO, EXPLAIN SCOPE OF IS THE AUDIT REPORT RENDERED DIRECTLY TO THE PROPRIETOR, PARTNERSIF A PARTNERSHIP OR BOARD OF DIRECTORS IF A CORPORATION?

6 6. DATE OF COMPLETION OF LAST AUDIT OF:CASH & ACCOUNTSINVENTORY7. WERE ANY DISCREPANCIES OR LOOSE PRACTICES COMMENTED UPON IN THISAUDIT? IF "YES", SUBMIT A COPY OF THE AUDIT AND AUDITOR S IS THERE AN INTERNAL AUDIT BY AN INTERNAL AUDIT DEPARTMENT UNDER THECONTROL OF AN EMPLOYEE WHO IS A PUBLIC ACCOUNTANT OR "YES", ARE THE REPORTS RENDERED DIRECTLY TO THE PROPRIETOR,PARTNERS IF A PARTNERSHIP OR BOARD OF DIRECTORS IF A CORPORATION?EXPLAIN ALL "NO" RESPONSES IN REMARKSYESNOEXPLAIN ALL "NO" RESPONSES IN REMARKSYESNO1. ARE BANK ACCOUNTS RECONCILED BY SOMEONE NOT AUTHORIZED TO DEPOSITOR WITHDRAW?2. IS COUNTERSIGNATURE OF CHECKS REQUIRED?3. ARE SECURITIES SUBJECT TO JOINT CONTROL OF TWO OR MORERESPONSIBLE EMPLOYEES?ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCEOR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CON-CERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND[NY: SUBSTANTIAL] CIVIL PENALTIES.

7 (NOT APPLICABLE IN CO, HI, NE, OH, OK, OR; IN ME AND VA, INSURANCE BENEFITS MAY ALSO BE DENIED)