Fidelity Guarantee Insurance Policy Proposal Form

Company Name*

Phone*

Email*

Address*

Trade/Business Type

Date of Establishment

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

If “Yes”, please give full details

a) Declined a proposal, refused renewal or cancelled any insurance?YesNo

b) Required an increased premium or imposed special conditions?YesNo

If “Yes”, please give full details

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

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

1. Do you have an internal audit department?*YesNo

If YES, to whom does the department manager report?

If YES, how frequently are all areas of the business audited?

2. Do external auditors examine your accounts every twelve months?*YesNo

Who are your external auditors?

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

If YES, what is the limit?

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

If No, what is the predetermined limit above which
two signatures are required?

Names of persons, designations who are authorized to
Sign the cheques

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

If 'Yes', at what intervals?

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
If YES:
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

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? (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

Limit of Indemnity required: Per employee

Limit of Indemnity required: Total for all employees

Total Limit of Indemnity required for all employees