ACORD 141 (2014/12) - CRIME SECTION 2000

ACORD 141 (2014/12) - CRIME SECTION 2000
ACORD 141, Crime Section 2000, is used to apply for Crime coverage to companies that have adopted the 2000 ISO Crime Program.
Use this form in conjunction with the Commercial Insurance Application, Applicant Information Section, ACORD 125. Refer to ACORD 125 for
information on that form.
Form Page 1
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Location #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
IDENTIFICATION SECTION
Date
Enter date: The date on which the form is completed. (MM/DD/YYYY)
IDENTIFICATION SECTION
Agency
Enter text: The full name of the producer / agency.
IDENTIFICATION SECTION
Policy Number
Enter identifier: The identifier assigned by the insurer to the policy, or submission, being
referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for
self-insurance, the self-insured license or contract number.
IDENTIFICATION SECTION
Effective Date
Enter date: The effective date of the policy. The date that the terms and conditions of the policy
commence. (MM/DD/YYYY)
IDENTIFICATION SECTION
Carrier
Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use
the actual name of the company within the group to which the policy has been issued. This is
not the insurer's group name or trade name.
IDENTIFICATION SECTION
NAIC Code
Enter code: The identification code assigned to the insurer by the NAIC.
IDENTIFICATION SECTION
Applicant (First Named
Insured)
Enter text: The named insured(s) as it / they will appear on the policy declarations page.
IDENTIFICATION SECTION
Basis For Coverage -
Discovery
Check the box (if applicable): Indicates the basis for coverage is Discovery.
IDENTIFICATION SECTION
Basis For Coverage - Loss
Sustained
Check the box (if applicable): Indicates the basis for coverage is Loss Sustained.
COVERAGE
Employee Theft Blanket
Check the box (if applicable): Indicates the employee theft coverage is written on a blanket
basis.
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COVERAGE
Employee Theft Schedule
Check the box (if applicable): Indicates the employee theft coverage is written on a schedule
basis.
COVERAGE
Employee Theft Limit
Amount
Enter limit: The limit for the employee theft coverage.
COVERAGE
Employee Theft Deductible
Enter limit: The deductible for the employee theft coverage.
COVERAGE
ERISA
Check the box (if applicable): Indicates coverage is requested for Employee Retirement Income
Security Act (ERISA).
COVERAGE
Limit
Enter limit: The limit for ERISA coverage.
COVERAGE
Aggregate
Enter limit: The aggregate limit for ERISA coverage.
COVERAGE
ERISA excess amount over
blanket limit
Enter limit: The ERISA excess amount over the blanket limit.
COVERAGE
Total Asset Value
Enter limit: The total asset value for ERISA coverage.
COVERAGE
Total Asset Value (per plan)
Enter limit: The total asset value (per plan) for ERISA coverage.
COVERAGE
Employee Theft
Governmental Crime -
Blanket
Check the box (if applicable): Indicates the coverage is written on a blanket basis.
COVERAGE
Employee Theft
Governmental Crime -
Schedule
Check the box (if applicable): Indicates the coverage is written on a schedule basis.
COVERAGE
Employee Theft
Governmental Crime - Per
Loss
Check the box (if applicable): Indicates the coverage is written on a per loss basis.
COVERAGE
Employee Theft
Governmental Crime - Per
Employee
Check the box (if applicable): Indicates the coverage is written on a per employee basis.
COVERAGE
Employee Theft
Governmental Crime Limit
Amount
Enter limit: The limit for employee theft governmental crime coverage.
COVERAGE
Employee Theft
Governmental Crime
Deductible
Enter deductible: The deductible for employee theft governmental crime coverage.
COVERAGE
Forgery or Alteration Limit
Amount
Enter limit: The limit for forgery or alteration coverage.
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COVERAGE
Forgery or Alteration
Deductible
Enter deductible: The deductible for forgery or alteration coverage.
COVERAGE
Theft of Money and
Securities - Blanket
Check the box (if applicable): Indicates the coverage is written on a blanket basis.
COVERAGE
Theft of Money and
Securities - Schedule
Check the box (if applicable): Indicates the coverage is written on a schedule basis.
COVERAGE
Theft of Money and
Securities Limit Amount
Enter limit: The limit for inside the premises theft of money and securities coverage.
COVERAGE
Theft of Money and
Securities Deductible
Enter deductible: The deductible for inside the premises theft of money and securities coverage.
COVERAGE
Robbery or Burglary of
Other Property - Blanket
Check the box (if applicable): Indicates the coverage is written on a blanket basis.
COVERAGE
Robbery or Burglary of
Other Property - Schedule
Check the box (if applicable): Indicates the coverage is written on a schedule basis.
COVERAGE
Robbery or Burglary of
Other Property Limit
Amount
Enter limit: The limit for inside the premises robbery or burglary of other property coverage.
COVERAGE
Robbery or Burglary of
Other Property Deductible
Enter deductible: The deductible for inside the premises robbery or burglary of other property
coverage.
COVERAGE
Money and Securities Limit
Amount
Enter limit: The limit for outside the premises money and securities coverage.
COVERAGE
Money and Securities
Deductible
Enter deductible: The deductible for outside the premises money and securities coverage.
COVERAGE
Other Property - Blanket
Check the box (if applicable): Indicates the coverage is written on a blanket basis.
COVERAGE
Other Property - Schedule
Check the box (if applicable): Indicates the coverage is written on a schedule basis.
COVERAGE
Other Property Limit
Amount
Enter limit: The limit for outside the premises other property coverage.
COVERAGE
Other Property Deductible
Enter deductible: The deductible for outside the premises other property coverage.
COVERAGE
Computer Fraud Limit
Amount
Enter limit: The limit for computer fraud coverage.
COVERAGE
Computer Fraud Deductible
Enter deductible: The deductible for computer fraud coverage.
COVERAGE
Funds Transfer Fraud Limit
Amount
Enter limit: The limit for funds transfer fraud coverage.
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COVERAGE
Funds Transfer Fraud
Deductible
Enter deductible: The deductible for funds transfer fraud coverage.
COVERAGE
Money Orders and
Counterfeit Paper Currency
Limit Amount
Enter limit: The limit for money orders and counterfeit paper currency coverage.
COVERAGE
Money Orders and
Counterfeit Paper Currency
Deductible
Enter deductible: The deductible for money orders and counterfeit paper currency coverage.
COVERAGE
Coverage Description
Enter text: The description of the coverage endorsements.
COVERAGE
Coverage Limit
Enter limit: The limit amount for the coverage.
COVERAGE
Coverage Deductible
Enter deductible: The deductible amount for the coverage.
COVERAGE
ENDORSEMENTS
Coverage Endorsements
Enter text: The description of the coverage endorsements.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION
Name of Plan
Enter text: The name of the employee benefit plan, such as ERISA.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION
Principal Address
Enter text: The employee benefit plan's first address line.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION
Enter text: The employee benefit plan's second address line.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION
Enter text: The employee benefit plan's city.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION
Enter code: The employee benefit plan's state or province code.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION
Enter code: The employee benefit plan's postal code.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION
Number of Trustees,
Employees, etc Handling
Plan Assets
Enter number: The number of trustees, employees, etc. handling plan assets.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION
Number of Plan Participants
Enter number: The number of plan participants.
ERISA EMPLOYEE THEFT -
ADDITIONAL INFORMATION investing of funds under
Is there a licensed securities
firm responsible for
plan(s)? Yes/No
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there a licensed securities firm responsible for investing of funds under plan(s)?.
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GENERAL INFORMATION
1. Are volunteers used? (If
yes, # of volunteers)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are volunteers used?.
GENERAL INFORMATION
(If yes, # of volunteers)
Enter number: The number of volunteers used.
GENERAL INFORMATION
2. Any employee leased to
others?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any employees leased to others?.
GENERAL INFORMATION
Number of Employees
Leased to Others
Enter number: The number of employees leased to others.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether any employees are leased to others.
GENERAL INFORMATION
3. Any employees leased
from others?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any employees leased from others?.
GENERAL INFORMATION
Number of Employees
Leased from Others
Enter number: The number of employees leased from others.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether any employees are leased from others.
GENERAL INFORMATION
4. Any employees perform
money investing or trading?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any employees perform money investing or trading?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether any employees perform money investing or trading.
GENERAL INFORMATION
5. Any employees receive or
issue warehouse receipts?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any employees receive or issue warehouse receipts?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether any employees receive or issue warehouse receipts.
GENERAL INFORMATION
6. Any employee(s) been
cancelled for crime
coverage by any insurer?
(Missouri Applicants - Do
not answer this question)
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any employee(s) been cancelled for crime coverage by any insurer?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether any employee(s) has / have been canceled for crime
coverage by any insurer.
GENERAL INFORMATION
7. Does applicant have any
written agreements with
clients?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant have any written agreements with clients?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the applicant has any written agreement with clients.
GENERAL INFORMATION
8. Does applicant transfer
any funds by phone or fax?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does applicant transfer any funds via phone or fax?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether the applicant transfers any funds via phone or fax.
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GENERAL INFORMATION
9. Any exposure from loss
to guest property? Yes
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Any exposure from loss to guest property?.
GENERAL INFORMATION
Explain
Enter text: An explanation as to whether there is any exposure from loss to guest property.
Form Page 2
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Location #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Accountants and Assts
Enter number: The number of employees that are accountants and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Adjusters
Enter number: The number of employees that are adjusters.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Administrators and Assts
Enter number: The number of employees that are administrators and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Appraisers and Clerks
Acting As Appraisers
Enter number: The number of employees that are appraisers and clerks acting as appraisers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Attorneys
Enter number: The number of employees that are attorneys.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Auditors and Assts
Enter number: The number of employees that are auditors and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Bookkeepers
Enter number: The number of employees that are bookkeepers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Bus Drivers
Enter number: The number of employees that are bus drivers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Buyers and Assts
Enter number: The number of employees that are buyers and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Canvassers (Door-to-Door
Salespeople)
Enter number: The number of employees that are canvassers (door-to-door salespeople).
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Cashiers and Assts
Enter number: The number of employees that are cashiers and assistants.
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CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Chairpersons
Enter number: The number of employees that are chairpersons.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Chefs Who Order Food
Enter number: The number of employees that are chefs who order food.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Collectors
Enter number: The number of employees that are collectors.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Computer Programmers
Enter number: The number of employees that are computer programmers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Comptrollers and Assts
Enter number: The number of employees that are comptrollers and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Credit Clerks and Managers
Enter number: The number of employees that are credit clerks and managers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Custodians
Enter number: The number of employees that are custodians.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Delivery Persons
Enter number: The number of employees that are delivery persons.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Demonstrators
Enter number: The number of employees that are demonstrators.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Dietitians Who Order Food
Enter number: The number of employees that are dietitians who order food.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Drivers and Drivers' Helpers
Enter number: The number of employees that are drivers and drivers' helpers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Food Inspectors
Enter number: The number of employees that are food inspectors.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Head Pharmacists
Enter number: The number of employees that are head pharmacists.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Instructors Having Custody
of Money or Securities
Enter number: The number of employees that are instructors having custody of money and
securities.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Janitors
Enter number: The number of employees that are janitors.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Locker Room Attendants
Enter number: The number of employees that are locker room attendants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Maitre D's and Assts
Enter number: The number of employees that are maitre d's and assistants.
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CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Managers and Assts
Enter number: The number of employees that are managers and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Medical Directors
Enter number: The number of employees that are medical directors.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Messengers, Outside
Enter number: The number of employees that are messengers, outside.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Payroll Distributors
Enter number: The number of employees that are payroll distributors.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Purchasing Agents and
Assts
Enter number: The number of employees that are purchasing agents and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Receiving Clerks
Enter number: The number of employees that are receiving clerks.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Refinery Gaugers of Oil
Companies Handling
Refined Gasoline and Oils
Enter number: The number of employees that are refinery gaugers of oil companies handling
refined gasoline and oils.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Salespeople
Enter number: The number of employees that are salespeople.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Security Personnel
Enter number: The number of employees that are security personnel.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Service Station Attendants
Enter number: The number of employees that are service station attendants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Shipping Clerks
Enter number: The number of employees that are shipping clerks.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Stock Clerks
Enter number: The number of employees that are stock clerks.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Storekeepers
Enter number: The number of employees that are storekeepers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Storeroom Personnel
Enter number: The number of employees that are storeroom personnel.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Superintendents and Assts
Enter number: The number of employees that are superintendents and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Supervisors and Assts
Enter number: The number of employees that are supervisors and assistants.
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CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Taxi Drivers
Enter number: The number of employees that are taxi drivers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Teachers Having Custody of
Money or Securities
Enter number: The number of employees that are teachers having custody of money or
securities.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Timekeepers and Assts
Enter number: The number of employees that are timekeepers and assistants.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Truck Drivers
Enter number: The number of employees that are truck drivers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Warehouse Personnel
Enter number: The number of employees that are warehouse personnel.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Wine Cellar Personnel
Enter number: The number of employees that are wine cellar personnel.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Wine Stewards / Esses
Enter number: The number of employees that are wine stewards / stewardesses.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
All Other Officers and
Employees Not Listed
Above
Enter number: The number of all other officers and employees not listed elsewhere.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Number of Officers
Enter number: The number of officers.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Total Number of Other
Employees
Enter number: The number of other employees.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
Manufacturers, Processors,
Wholesalers or Distributors
Enter number: The number of retail locations.
CLASSIFICATION OF
EMPLOYEES / LOCATIONS
All Other Classes
Enter number: The number of locations other than home or head offices.
HIRING PRACTICES
1. Is prior employer history
checked?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is prior employer history checked?.
HIRING PRACTICES
2. Is education and training
verified?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is education and training verified?.
HIRING PRACTICES
3. Is drug testing
conducted?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is drug testing conducted?.
HIRING PRACTICES
4. Is a formal training
program established and
followed?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is a formal training program established and followed?.
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HIRING PRACTICES
5. Are credit checks secured
for employees with access
to financial transactions?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are credit checks secured for employees with access to financial transactions?.
HIRING PRACTICES
6. Are social security
numbers verified?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are social security numbers verified?.
HIRING PRACTICES
7. Is criminal history
checked?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is criminal history checked?.
HIRING PRACTICES
8. Are managers provided
with names and salaries of
all assigned employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are managers provided with names and salaries of all assigned employees?.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
1. Is There An Audit By?
CPA
Check the box (if applicable): Indicates the audit is performed by a Certified Public Accountant
(CPA).
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Public Accountant
Check the box (if applicable): Indicates the audit is performed by a Public Accountant.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Staff
Check the box (if applicable): Indicates the audit is performed by staff.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Other
Check the box (if applicable): Indicates the audit is performed by someone other than those
listed.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Other Description
Enter text: The person that performs this audit.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
2. Name and Address of
Person or Firm Performing
Audit
Enter text: The name of the person or firm performing the audit.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Enter text: The auditor's mailing address first address line.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Enter text: The auditor's mailing address second address line.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Enter text: The auditor's mailing address city.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Enter code: The auditor's mailing address state or province code.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Enter code: The auditor's mailing address postal code.
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CONTROLS AND AUDIT
PROCEDURES - AUDITS
3. Date of completion of last
audit of cash & accounts
Enter date: The date the last audit of cash and accounts was completed. (MM/DD/YYYY)
CONTROLS AND AUDIT
PROCEDURES - AUDITS
3. Date of completion of last
audit of inventory
Enter date: The date the last audit of inventory was completed. (MM/DD/YYYY)
CONTROLS AND AUDIT
PROCEDURES - AUDITS
4. Audit Frequency: Annual
Check the box (if applicable): Indicates audits are performed annually.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Semi-Annual
Check the box (if applicable): Indicates audits are performed semi-annually.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Quarterly
Check the box (if applicable): Indicates audits are performed quarterly.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Other Frequency
Check the box (if applicable): Indicates audits are performed other than the frequencies listed.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Describe Other Frequency
Enter text: The audit frequency.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
5. Audit report is rendered
to: Owner
Check the box (if applicable): Indicates the audit is rendered to the owner.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Partners
Check the box (if applicable): Indicates the audit is rendered to the partners.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Board of Directors
Check the box (if applicable): Indicates the audit is rendered to the board of directors.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Other
Check the box (if applicable): Indicates the audit is rendered to other than those listed.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Other Description
Enter text: The person(s) the audit is rendered to.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
6. Financial format is: Audit
Check the box (if applicable): Indicates the financial format is an audit.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Review
Check the box (if applicable): Indicates the financial format is a review.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Compilation
Check the box (if applicable): Indicates the financial format is a compilation.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Tax Return Only
Check the box (if applicable): Indicates the financial format is a tax return only.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
7. Are all locations audited?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are all locations audited?.
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CONTROLS AND AUDIT
PROCEDURES - AUDITS
8. Is audit made in
accordance with generally
accepted auditing standards
and so certified? If no
explain scope of audit.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is audit made in accordance with generally accepted auditing standards and so certified?. If
no, explain scope of audit.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
Explain
Enter text: An explanation as to whether an audit is made in accordance with generally accepted
auditing standards and so certified.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
9. Were any discrepancies
or loose practices
commented upon this
audit? If yes, submit a
copy of the audit and
auditor's comments.
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Were any discrepancies or loose practices commented upon in this audit?. If yes, submit a
copy of the audit and auditor's comments.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
10. Does audit include
inventory?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does audit include inventory?.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
11. Are references of all new
hires checked with respect
to employment history?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are references of all new hires checked with respect to employment history?.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
12. Does audit department
have a program to detect
ghost employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Does audit department have a program to detect ghost employees?.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
13. Is payroll system
audited annually?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is payroll system audited annually?.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
14. Is a complete physical
inventory made?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is a complete physical inventory made?.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
How Often?
Enter text: The frequency that a physical inventory is made.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
15. Is inventory made by
persons who do not have
custody control?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is inventory made by persons who do not have custody control?.
CONTROLS AND AUDIT
PROCEDURES - AUDITS
16. Is a requisition /
shipping order required for
removal of goods from
storeroom / warehouse?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is a requisition / shipping order required for removal of goods from storeroom / warehouse?.
Form Page 3
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Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Location #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
1. Are bank accounts
reconciled by someone not
authorized to deposit or
withdraw?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are bank accounts reconciled by someone not authorized to deposit or withdraw?.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
2. Is countersignature of
checks required? If not,
who signs controls?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is countersignature of checks required?. If No, explain who signs controls.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
If not, who signs controls?
Enter text: The full name of the person who signs controls if countersignatures are not required.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
3. Will securities be subject
to joint control of two or
more responsible
employees?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are securities subject to joint control of two or more responsible employees?.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
4. Are all officers and
employees required to take
annual vacations of at least
five consecutive business
days?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are all officers and employees required to take annual vacations of at least five consecutive
business days?.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
5. Is there a written policy
on EFTS?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there written policy regarding (electronic funds transfer) EFTs?.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
6. What is the largest single
amount that can be
transferred?
Enter amount: The maximum amount that can be transferred via electronic funds transfer.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
7. Prior to funds transfer,
does financial institution
verify authenticity with
another employee?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Prior to funds transfer, does financial institution verify authenticity with another employee?.
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CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
8. Are hard copies of funds
transfer confirmations
received and reconciled?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are hard copies of funds transfer confirmations received and reconciled?.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
9. Frequency of deposits:
Daily
Check the box (if applicable): Indicates deposits are made daily.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
Frequency of deposits:
Other Frequency
Check the box (if applicable): Indicates deposits are made other than those frequencies listed.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
Describe Other Frequency
Enter text: The frequency deposits are made.
CONTROLS AND AUDIT
PROCEDURES - BANKING /
OTHER
10. Are detailed records of
bank deposits maintained?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are detailed records of bank deposits maintained?.
MONEY- SECURITIES
Inside Money
Enter amount: The maximum exposure amount for money. As used here, this refers to items
inside.
MONEY- SECURITIES
Inside Checks for Deposit
Enter amount: The maximum exposure amount for checks for deposit. As used here, this refers
to items inside.
MONEY- SECURITIES
Inside Checks for Accounts
Payable
Enter amount: The maximum exposure amount for checks for accounts payable. As used here,
this refers to items inside.
MONEY- SECURITIES
Inside Payroll Checks
Enter amount: The maximum exposure amount for payroll checks. As used here, this refers to
items inside.
MONEY- SECURITIES
Inside Money Overnight
Enter amount: The maximum exposure amount for money overnight. As used here, this refers
to items inside.
MONEY- SECURITIES
Inside Securities (In
Bank/Safe Deposit)
Enter amount: The maximum exposure amount for securities. As used here, this refers to items
inside.
MONEY- SECURITIES
Messenger 1 Money
Enter amount: The maximum exposure amount for money. As used here, this refers to money
with a messenger.
MONEY- SECURITIES
Messenger 1 Checks for
Deposit
Enter amount: The maximum exposure amount for checks for deposit. As used here, this refers
to checks for deposit with a messenger.
MONEY- SECURITIES
Messenger 1 Checks for
Accounts Payable
Enter amount: The maximum exposure amount for checks for accounts payable. As used here,
this refers to checks for accounts payable with a messenger.
MONEY- SECURITIES
Messenger 1 Payroll Checks
Enter amount: The maximum exposure amount for payroll checks. As used here, this refers to
payroll checks with a messenger.
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MONEY- SECURITIES
Messenger 1 Money
Overnight
Enter amount: The maximum exposure amount for money overnight. As used here, this refers
to money overnight with a messenger.
MONEY- SECURITIES
Messenger 2 Money
Enter amount: The maximum exposure amount for money. As used here, this refers to money
with a messenger.
MONEY- SECURITIES
Messenger 2 Checks for
Deposit
Enter amount: The maximum exposure amount for checks for deposit. As used here, this refers
to checks for deposit with a messenger.
MONEY- SECURITIES
Messenger 2 Checks for
Accounts Payable
Enter amount: The maximum exposure amount for checks for accounts payable. As used here,
this refers to checks for accounts payable with a messenger.
MONEY- SECURITIES
Messenger 2 Payroll Checks
Enter amount: The maximum exposure amount for payroll checks. As used here, this refers to
payroll checks with a messenger.
MONEY- SECURITIES
Messenger 2 Money
Overnight
Enter amount: The maximum exposure amount for money overnight. As used here, this refers
to money overnight with a messenger.
PURCHASING / RECEIVING
CONTROLS
1. Are duties segregated?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are duties segregated?.
PURCHASING / RECEIVING
CONTROLS
2. Are departments
supervised by someone not
authorized to pay bills?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are departments supervised by someone not authorized to pay bills?.
PURCHASING / RECEIVING
CONTROLS
3. Is responsibility for
checking merchandise
received, controlled by more
than one individual?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is responsibility for checking merchandise received, controlled by more than one individual?.
PURCHASING / RECEIVING
CONTROLS
4. Is actual receipt of
merchandise verified before
a payment is made?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is actual receipt of merchandise verified before payment is made?.
PURCHASING / RECEIVING
CONTROLS
5. Is a numbered purchase
order system implemented
and followed?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is a numbered purchase order system implemented and followed?.
COMPUTER FRAUD
CONTROLS
1. Do internal audit
procedures include
computer operations?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Do internal audit procedures include computer operations?.
COMPUTER FRAUD
CONTROLS
2. Is there an employee or
department whose sole duty
is security?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is there an employee or department whose sole duty is security?.
COMPUTER FRAUD
CONTROLS
3. Are suspicious
transactions reviewed and
investigated?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Are suspicious transactions reviewed and investigated?.
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COMPUTER FRAUD
CONTROLS
4. Is physical access to
computer room and
equipment restricted to
authorized personnel?
Enter Y for a Yes response. Input N for No response. Indicates the response to the question,
Is physical access to computer room and equipment restricted to authorized personnel?.
PROPERTY
Description of Property,
Merchandise. etc.
Enter text: The complete description of the property including merchandise and stock.
PROPERTY
Maximum Value
Enter amount: The maximum value of the property.
MISCELLANEOUS
INFORMATION
Business Hours
Enter time: The starting time for the normal business day.
MISCELLANEOUS
INFORMATION
Enter time: The closing time for the normal business day.
MISCELLANEOUS
INFORMATION
Avg # Employees on Duty
Enter number: The average number of employees on duty during the normal business hours.
MISCELLANEOUS
INFORMATION
Checks Stamped for Deposit
Only? Y / N
Enter Y for a Yes response. Input N for No response. Indicates if checks are stamped For
Deposit Only.
MISCELLANEOUS
INFORMATION
Frequency of Deposits
Enter code: The frequency of deposits.
MISCELLANEOUS
INFORMATION
Night Depository Used? Y /
N
Enter Y for a Yes response. Input N for No response. Indicates if a night depository is used.
MISCELLANEOUS
INFORMATION
Annual Gross Sales or
Receipts for Last Fiscal
Year
Enter amount: The annual gross sales or receipts for the last fiscal year
MISCELLANEOUS
INFORMATION
Does Premises Have Double
Cylinder Door Locks? Y / N
Enter Y for a Yes response. Input N for No response. Indicates the type of locks on the entry
doors of the insured premises are double cylinder deadbolt door locks.
MISCELLANEOUS
INFORMATION
Other Information
Enter text: The description of any supplemental information such as police patrol, central
shopping center guard
information, proprietary closed circuit television, etc.
Form Page 4
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Location #
Enter number: The location number for the premises.
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Page 16 of 26
IDENTIFICATION SECTION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
SAFE / VAULT
Manufacturer One
Enter text: The safe or vault manufacturer's name.
SAFE / VAULT
Label UL One
Check the box (if applicable): Indicates the rating is based on Underwriters Laboratories, Inc.
(UL).
SAFE / VAULT
Label SMNA One
Check the box (if applicable): Indicates the rating is based on Safe Manufacturers National
Association (SMNA).
SAFE / VAULT
Class One
Enter code: The construction classification representing the extent of burglary protection for this
safe or vault. Use the classification from the Burglary label and not the Fire label located on the
safe or vault. For industry definitions of the classifications, refer to the Commercial Lines
Manual.
SAFE / VAULT
Door Type Round One
Check the box (if applicable): Indicates the door is round.
SAFE / VAULT
Door Type Square One
Check the box (if applicable): Indicates the door is square.
SAFE / VAULT
Combination Locks Outer
One
Check the box (if applicable): Indicates if there are outer combination locks on the safe or vault.
SAFE / VAULT
Combination Locks Inner
One
Check the box (if applicable): Indicates if there are inner combination locks on the safe or vault.
SAFE / VAULT
Combination Locks Chest
One
Check the box (if applicable): Indicates if there are chest combination locks on the safe or vault.
SAFE / VAULT
Thickness Door (excluding
Bolt Work) One
Enter number: The door thickness in inches, excluding bolt work.
SAFE / VAULT
Thickness Wall One
Enter number: The wall thickness in inches.
SAFE / VAULT
Manufacturer Two
Enter text: The safe or vault manufacturer's name.
SAFE / VAULT
Label UL Two
Check the box (if applicable): Indicates the rating is based on Underwriters Laboratories, Inc.
(UL).
SAFE / VAULT
Label SMNA Two
Check the box (if applicable): Indicates the rating is based on Safe Manufacturers National
Association (SMNA).
SAFE / VAULT
Class Two
Enter code: The construction classification representing the extent of burglary protection for this
safe or vault. Use the classification from the Burglary label and not the Fire label located on the
safe or vault. For industry definitions of the classifications, refer to the Commercial Lines
Manual.
SAFE / VAULT
Door Type Round Two
Check the box (if applicable): Indicates the door is round.
SAFE / VAULT
Door Type Square Two
Check the box (if applicable): Indicates the door is square.
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SAFE / VAULT
Combination Locks Outer
Two
Check the box (if applicable): Indicates if there are outer combination locks on the safe or vault.
SAFE / VAULT
Combination Locks Inner
Two
Check the box (if applicable): Indicates if there are inner combination locks on the safe or vault.
SAFE / VAULT
Combination Locks Chest
Two
Check the box (if applicable): Indicates if there are chest combination locks on the safe or vault.
SAFE / VAULT
Thickness Door (excluding
Bolt Work) Two
Enter number: The door thickness in inches, excluding bolt work.
SAFE / VAULT
Thickness Wall Two
Enter number: The wall thickness in inches.
MESSENGER PROTECTION
Mess'gr # One
Enter identifier: The producer assigned identifier for the messenger.
MESSENGER PROTECTION
# of Guards Per Messenger
One
Enter number: The number of guards assigned to work with each messenger.
MESSENGER PROTECTION
# of Armored Vehicles
Enter number: The number of armored vehicles to which the limits apply.
MESSENGER PROTECTION
Private Conveyance Used?
One
Enter Y for a Yes response. Input N for No response. Indicate if the messenger uses a car or
truck provided for his/her exclusive use during the
entire trip.
MESSENGER PROTECTION
Safety Satchel Used? One
Enter Y for a Yes response. Input N for No response. Indicate if the insured's property is
carried in an Underwriters Laboratories-approved
safety satchel (e.g., a key-locked bank depository bag or case with handcuffs).
MESSENGER PROTECTION
Mess'gr # Two
Enter identifier: The producer assigned identifier for the messenger.
MESSENGER PROTECTION
# of Guards Per Messenger
Two
Enter number: The number of guards assigned to work with each messenger.
MESSENGER PROTECTION
# of Armored Vehicles
Enter number: The number of armored vehicles to which the limits apply.
MESSENGER PROTECTION
Private Conveyance Used?
Two
Enter Y for a Yes response. Input N for No response. Indicate if the messenger uses a car or
truck provided for his/her exclusive use during the
entire trip.
MESSENGER PROTECTION
Safety Satchel Used? Two
Enter Y for a Yes response. Input N for No response. Indicate if the insured's property is
carried in an Underwriters Laboratories-approved
safety satchel (e.g., a key-locked bank depository bag or case with handcuffs).
PREMISES / SAFE
PROTECTION
Alarm Type - Hold-Up
Check the box (if applicable): Indicates the alarm type is a hold-up alarm. A manual or
semiautomatic control which can transmit an alarm in the event of a hold-up.
PREMISES / SAFE
PROTECTION
Alarm Type - Premises
Check the box (if applicable): Indicates the alarm type is a premises alarm. A sensing device
installed on premises which transmits an alarm in the event of unauthorized entry. The Premises
Extent must be completed for Premises Alarms.
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PREMISES / SAFE
PROTECTION
Alarm Type - Safe
Check the box (if applicable): Indicates the alarm type is a safe / vault alarm. A system that
protects the safe or vault and is connected to an outside central station, gong or siren. The
Extent of Protection for safe / vault must be completed.
PREMISES / SAFE
PROTECTION
Alarm Description - Local
Gong
Check the box (if applicable): Indicates the burglar alarm sounds or appears outside the
premises.
PREMISES / SAFE
PROTECTION
Alarm Description - Central
Station
Check the box (if applicable): Indicates the burglar alarm rings at an alarm company.
PREMISES / SAFE
PROTECTION
Alarm Description - Police
Connect
Check the box (if applicable): Indicates if alarms (hold-up and burglar) are transmitted to police
headquarters rather than to a private control station
PREMISES / SAFE
PROTECTION
Alarm Description - With
Keys
Check the box (if applicable): Indicates the alarm company, located off the insured's premises,
has keys to the applicant's property.
PREMISES / SAFE
PROTECTION
Grade
Enter code: The alarm grade as described in the Insurance Services Office crime rating manual
(e.g., AA, A, B, C) which indicates the time required to respond to a signal from the alarm
system.
PREMISES / SAFE
PROTECTION
Safe / Vault - Partial
Check the box (if applicable): Indicates the extent of protection for the safe / vault is partial and
covers around the door only.
PREMISES / SAFE
PROTECTION
Safe / Vault - Complete
Check the box (if applicable): Indicates the extent of protection for the safe / vault is complete
and covers the sides, top walls, floor and ceiling.
PREMISES / SAFE
PROTECTION
Premises 1
Check the box (if applicable): Indicates the extent of protection for the premises is premises 1
as defined in the ISO Classification and Rating Manual.
PREMISES / SAFE
PROTECTION
Premises 2
Check the box (if applicable): Indicates the extent of protection for the premises is premises 2
as defined in the ISO Classification and Rating Manual.
PREMISES / SAFE
PROTECTION
Premises 3
Check the box (if applicable): Indicates the extent of protection for the premises is premises 3
as defined in the ISO Classification and Rating Manual.
PREMISES / SAFE
PROTECTION
Alarm Installed and Serviced
By
Enter text: The name of the alarm company that installed and services the alarm. Alarm
companies often install, maintain, and service the system in addition to providing Central Station
facilities.
PREMISES / SAFE
PROTECTION
# Guards
Enter number: The number of guards within the premises or at its door during regular business
hours.
PREMISES / SAFE
PROTECTION
# Watch Persons
Enter number: The number of watchpersons on the premises during non-office hours.
PREMISES / SAFE
PROTECTION
Watchpersons RPT/Cent St
Check the box (if applicable): Indicates the watchpersons report to a central station on an hourly
basis.
PREMISES / SAFE
PROTECTION
Watchpersons Clock Hrly
Check the box (if applicable): Indicates the watchpersons register hourly with an approved
watchperson's clock (Detex Time Clock, etc.).
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PREMISES / SAFE
PROTECTION
Watchpersons Don't Signal
Check the box (if applicable): Indicates the watchpersons do not do any type of reporting or
registering.
PREMISES / SAFE
PROTECTION
Certificate Number
Enter identifier: The Underwriters Laboratories or other testing organization Certificate Number,
if applicable. Attach a copy of the certificate to the application.
PREMISES / SAFE
PROTECTION
Expiration Date
Enter date: The expiration date of the certificate. (MM/DD/YYYY) As used here, this is the
expiration date of the UL certificate.
PREMISES / SAFE
PROTECTION
Accessible Openings and
Protection
Enter text: The information regarding access to the premises. Indicate number of doors and if
they are protected. Indicate what type of locks are used, and if there is a gate or bars.
PREMISES / SAFE
PROTECTION
Other Protection
Enter text: The description of other protective measures or devices (e.g., if windows have steel
grates and are connected to an alarm). Indicate if the building has skylights and if windows are
visible from the street.
EMPLOYEE SCHEDULE
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee One
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title One
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit One
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible One
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Two
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Two
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Two
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Two
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Two
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Three
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Three
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Three
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Three
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Three
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Four
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Four
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Four
Enter text: The title this person has in the current employment position.
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EMPLOYEE SCHEDULE
Limit Four
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Four
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Five
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Five
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Five
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Five
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Five
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Six
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Six
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Six
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Six
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Six
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Seven
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Seven
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Seven
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Seven
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Seven
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Eight
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Eight
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Eight
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Eight
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Eight
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Nine
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Nine
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Nine
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Nine
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Nine
Enter limit: The deductible for the employee theft coverage.
ACORD 141 (2014/12) rev. 04-29-2014
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EMPLOYEE SCHEDULE
Loc # Ten
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Ten
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Ten
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Ten
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Ten
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Eleven
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Eleven
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Eleven
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Eleven
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Eleven
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Twelve
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Twelve
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Twelve
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Twelve
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Twelve
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Thirteen
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Thirteen
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Thirteen
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Thirteen
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Thirteen
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Fourteen
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Fourteen
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Fourteen
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Fourteen
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Fourteen
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Fifteen
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Fifteen
Enter text: The full name of the employee.
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EMPLOYEE SCHEDULE
Title Fifteen
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Fifteen
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Fifteen
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Sixteen
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Sixteen
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Sixteen
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Sixteen
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Sixteen
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Seventeen
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee
Seventeen
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Seventeen
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Seventeen
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Seventeen
Enter limit: The deductible for the employee theft coverage.
EMPLOYEE SCHEDULE
Loc # Eighteen
Enter identifier: The producer assigned identifier for the location where the employee works.
EMPLOYEE SCHEDULE
Name of Employee Eighteen
Enter text: The full name of the employee.
EMPLOYEE SCHEDULE
Title Eighteen
Enter text: The title this person has in the current employment position.
EMPLOYEE SCHEDULE
Limit Eighteen
Enter limit: The limit for the employee theft coverage.
EMPLOYEE SCHEDULE
Deductible Eighteen
Enter limit: The deductible for the employee theft coverage.
Form Page 5
Section Name
Field Name
Description
IDENTIFICATION SECTION
Agency Customer ID
Enter identifier: The customer's identification number assigned by the producer (e.g., agency or
brokerage).
IDENTIFICATION SECTION
Location #
Enter number: The location number for the premises.
IDENTIFICATION SECTION
Building #
Enter number: The building number for the premises. Used when more than one building exists
at an individual location.
ADDITIONAL LOCATIONS
Loc # One
Enter number: The location number for the premises.
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ADDITIONAL LOCATIONS
Address One
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
ADDITIONAL LOCATIONS
Loc # Two
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Two
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
ADDITIONAL LOCATIONS
Loc # Three
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Three
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
ADDITIONAL LOCATIONS
Loc # Four
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Four
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
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ADDITIONAL LOCATIONS
Loc # Five
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Five
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
ADDITIONAL LOCATIONS
Loc # Six
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Six
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
ADDITIONAL LOCATIONS
Loc # Seven
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Seven
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
ADDITIONAL LOCATIONS
Loc # Eight
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Eight
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
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ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
ADDITIONAL LOCATIONS
Loc # Nine
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Nine
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
ADDITIONAL LOCATIONS
Loc # Ten
Enter number: The location number for the premises.
ADDITIONAL LOCATIONS
Address Ten
Enter text: The first address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The second address line of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The city of the commercial structure.
ADDITIONAL LOCATIONS
Enter text: The county of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The state or province code of the commercial structure.
ADDITIONAL LOCATIONS
Enter code: The postal code of the commercial structure.
REMARKS
Remarks
Enter text: The general remarks for the Crime line of business.
SIGNATURE SECTION
Producer's Signature
Sign here: Accommodates the signature of the authorized representative (e.g., producer, agent,
broker, etc.) of the company(ies) listed on the document. This is required in most states.
SIGNATURE SECTION
Producer's Name
Enter text: The name of the authorized representative of the producer, agency and/or broker
that signed the form.
SIGNATURE SECTION
State Producer License
Number
Enter identifier: The State License Number of the producer.
SIGNATURE SECTION
Applicant's Signature
Sign here: Accommodates the signature of the applicant or named insured.
SIGNATURE SECTION
Date
Enter date: The date the form was signed by the named insured. (MM/DD/YYYY)
SIGNATURE SECTION
National Producer Number
Enter identifier: The National Producer Number (NPN) as defined in the National Insurance
Producer Registry (NIPR). Note: The NPN is not the same as the producer state license
number.
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