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Fidelity Guarantee Insurance Policy Proposal Form

    YesNo

    YesNo

    Has any insurer in respect of the risk to which this Proposal relates:

    YesNo

    YesNo

    YesNo

    YesNo

    SYSTEM OF CHECK

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    If No, what is the predetermined limit above which

    Names of persons, designations who are authorized to

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo
    If YES:
    YesNo
    YesNoNo Internal Auditors
    YesNo

    YesNo
    If YES:
    YesNo
    YesNo
    YesNo
    YesNo

    SCOPE OF WORK

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    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:

    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.