STATE OF FLORIDA
CRIME INSURANCE QUESTIONNAIRE
1. APPLICANT INFORMATION
(a) Name
Department/University:
Division:
(b) Physical address
Street Address:
City, State, Zip:
2. COVERAGE REQUESTED (please indicate all that apply)
(a) Employee Dishonesty
Covers the dishonest acts of employees relating to money, security, and other property.
(b) Excess Employee Dishonesty
Provides an additional amount of coverage for dishonest acts of employees relating to money, security, and other property.
(c) Faithful Performance of Duty
Covers the failure of any employee to faithfully perform his or her duty, as prescribed by law, when
such failure has a direct and immediate result of loss of money, security, or property.
(d) Theft, Disappearance, and Destruction
Covers the loss of money and securities, both inside and outside the premises, in the event of theft (other than employee theft), disappearance, or destruction.
INFORMATION FOR COVERAGE
1. EMPLOYEE DISHONESTY
a) Within your organization, how many employees fall into each of the following categories?
Class 1 Employees
All other Employees
*Division Total Count
Department Total Count
For the purposes of premium computation, Class 1 Employees are the ratable employees to be covered under this crime insurance policy. Ratable employees consist of all management positions (agency heads, assistant agency heads, directors, assistant directors, bureau chiefs, assistant bureau chiefs, supervisors, presidents, comptrollers, etc.); all officers; police officers; all employees who handle money; and all employees who have custody or maintain records of money, securities, and/or property (cashiers, accountants, bookkeepers, mail room personnel, etc.).
*This line is intended for those organizations completing separate forms by Division.
2. EXCESS EMPLOYEE DISHONESTY
a) Division/Bureau to be covered: ______
b) Total number of employees: ______
c) Limit of Insurance: $ ______
3. FAITHFUL PERFORMANCE OF DUTY
List the number of employees for each covered position.
Number of Position Description
Employees
4. THEFT, DISAPPEARANCE, AND DESTRUCTION
a) Total number of locations to be covered: ______
b) Briefly describe the cash and check exposure for each location along with a brief location description (e.g., museum, administrative offices, driver’s license office, toll collection booths).
INSIDE OUTSIDE Number of
Cash Checks Cash Checks Locations
$______$______$______$______
Location Description and physical address:
INSIDE OUTSIDE Number of
Cash Checks Cash Checks Locations
$______$______$______$______
Location Description and physical address:
INSIDE OUTSIDE Number of
Cash Checks Cash Checks Locations
$______$______$______$______
Location Description and physical address:
c) Briefly describe the security provided at the majority of the locations covered (e.g., burglar alarms, safes, vaults, guards). Attach a separate sheet if additional space is needed.
This coverage is provided on a blanket-basis for all locations. Because of the differences in values from one location to another, it may be necessary to list two or three values.
Completed by:
(Please Print)
Date: ______Telephone Number:
3
State Purchasing 04/2007