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Crime / Fidelity (Bond) Coverage Application


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LIONS CLUB / DISTRICT INTERNATIONAL
CRIME PROTECTION PLUS APPLICATION
(for limits less than $1,000,000)

All fields are required. Use N/A if not applicable.

Lions Club/District:
Address: Address Cont:
City: State: Zipcode:
Telephone Number: Fax Number:
Website: http://
Contact Name: Contact Title:
Contact Phone Number: Contact Email:
Effective Date:
Annual Revenue:
THIS COVERAGE IS ONLY AVAILABLE IF DIRECTORS & OFFICERS LIABILITY COVERAGE IS PURCHASED.

DESIRED COVERAGE(S)

Employee Theft and Dishonesty $20,000 $50,000 $100,000
Note: Each of the above options includes $10,000 of coverage for Theft, Disappearance and Destruction – Inside the Premises and $10,000 for Theft, Disappearance and Destruction – Outside the Premises. Each option includes a $500 per claim deductible.
If higher limits are desired please specify
  Employee Theft: $
  Theft, Disappearance and Destruction – Inside the Premises: $
  Theft, Disappearance and Destruction – Outside the Premises: $

LOSS EXPERIENCE

List all crime losses sustained during the last three (3) years whether reimbursed or not. Check here if none:
 
Date of Loss: Total Amount of Loss:
Description of Loss and Corrective Action:  
Date of Loss: Total Amount of Loss:
Description of Loss and Corrective Action:  

MONEY AND SECURITIES EXPOSURES

Please indicate maximum exposure for each location if requesting limits higher than $10,000 for Money and Security coverage:
Date
Event
Cash
Retail Checks
Credit Card Reciepts and Non-Retail Checks*
Is There A Safe?
$ $ $ Yes No
$ $ $ Yes No
$ $ $ Yes No
$ $ $ Yes No
             
* A non-retail check is a check presented to you and immediately endorsed “for deposit only” and then recorded in your accounting process so that it could be re-created if it were stolen, lost or destroyed.
 
Is more than one Club/District member responsible for collecting funds from an event? Yes No
Is the money collected verified by more than one Club/District member at the close of the event? Yes No
Is money deposited within 24 hours of receipt? Yes No
Do members who reconcile the bank statements also:
  sign checks? Yes No
  make withdrawals? Yes No
  have access to blank checks? Yes No
Does the Club/District have procedures in place to safeguard all money collected? Yes No
If yes, please describe:

The undersigned declares that to the best of his or her knowledge and belief the statements set forth herein are true. The Company is hereby authorized to make any investigation and inquiry in connection with this application that it deems necessary.

Material Change

If there is any material change to the answers of this Application’s questions prior to the policy inception date, the Applicant must notify the Underwriter in writing. Any outstanding quotation may be modified or withdrawn.

WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

You must agree to the Fraud Notice Statements

The Undersigned warrants that to the best of his/her knowledge and belief the statements set forth herein are true. The Undersigned further declares that any occurrence or event that takes place prior to the effective date of the insurance applied for which may render inaccurate, untrue, or incomplete any statement made will immediately be reported in writing to the Underwriter. The Underwriter may withdraw or modify any outstanding quotations and/or authorization or agreement to bind the insurance. The Underwriter is hereby authorized to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The signing of this Application does not bind the Undersigned to purchase the insurance, nor does the review of this Application bind the insurance company to issue a policy. It is agreed that this Application shall be the basis of the contract should a policy be issued. This Application will be attached and become a part of the policy.


Name
Title		 (MUST BE SIGNED BY THE CLUB PRESIDENT, SECRETARY OR TREASURER / DISTRICT GOVERNOR, SECRETARY OR TREASURER FOR DISTRICT)

Date
Authorized Signature (if submitting paper copy)
The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons.

   

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