Address
Have there been any losses (whether insured or not) due to the dishonesty of employees, partners or directors during the last five years? YesNo
If “Yes”, please give full details
Has there been any occasion to question the honesty of any present or former employee during the last five years? YesNo
Has any insurer in respect of the risk to which this Proposal relates: a) Declined a proposal, refused renewal or cancelled any insurance? YesNo b) Required an increased premium or imposed special conditions? YesNo
A) Do you always obtain references directly from former employers for the three years immediately preceding engagement of employees responsible for money, goods or computer operations? YesNo
B) Are the references in writing? YesNo
If the answer is 'No' to either of the above, please describe your procedure
SYSTEM OF CHECK
1.Do you have an internal audit department? YesNo
2.Do external auditors examine your accounts every twelve months? YesNo
3.Are employees receiving cash and 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.Is there a predetermined limit above which manually prepared cheques or other bank instruments are required to have two signatures? YesNo
6.Does one signatory examine the supporting documentation before signing the cheque or instrument? YesNo
7.In the case of computer or machine produced cheque is the supporting documentation examined before the requisition is input? YesNo
8.Are all the cheques signed by two authorities? YesNo
9.Is cash in hand and petty cash checked independently of the employees responsible at least weekly? YesNo
10.Is the wages and salary documentation checked independently of the employees responsible before payment are made? YesNo
11.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
12.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
13.Are statements of account for all amounts due sent to customers by post at least monthly? YesNo
14.Is it your practice to ensure that employees who receive cash or cheques cannot interfere with the dispatch of statements of account and reminders for payments? YesNo
15.Is action taken at management level if an account becomes three months overdue? YesNo
16.Are any of your accounting, salary or stock control functions computerized? YesNo
If YES:
a) Are responsibilities for authorization of transactions, processing of transactions and handling of output exercised by different employees? YesNo b) Do your internal auditors supervise computer security? YesNoNo Internal Auditors c) Do your external auditors examine your computer security? YesNo
17.Do you use a 'Mainframe' computer? (i.e. not a 'personal computer') YesNo
a) Is access to the systems controlled by passcode procedures so that only staff with appropriate authority can enter? YesNo b) Do procedures exist to ensure that all changes to programs are authorized at the appropriate level? YesNo c) Is there an adequate system to check that these procedures have been complied with? YesNo d) Is a log kept showing all changes to programs? YesNo
SCOPE OF WORK
1. Do you wish to pay the first part of each claim? YesNo
2. Which of the following types of cover do you require? (Please tick only one option and answer the relevant section questions which follow) a) Cover the entire workforceb) Cover for employees in selected categories of occupations onlyc) Cover for named employees only
a) Cover for entire workforce:
b) Cover for employees in selected categories of occupations only:
c) Cover for named employees only:
DECLARATION 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.
We accept the terms & conditions of the above declaration
