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Municipal Entity Underwriting Application - page 6 / 34

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Municipal Entity Underwriting Application

Current Carrier

Unique Extensions or Exclusions

1.

If your entity desires an SIR program, does your entity have a preferred Third Party Administrator (TPA)?

If yes, complete the Third Party Administrator Information section.

 Yes

 No

2.

Coverage Descriptions.

Coverage

Limit

Retained Limit

Employee Theft:

Per Loss

Per Employee

Faithful Performance of Duty

 Yes

 No

Forgery or Alteration

Loss Inside Premises (Money & Securities/Theft, Disappearance & Destruction)

Loss Outside Premises (Money & Securities/Theft, Disappearance & Destruction)

Other:   

3.  Maximum Exposures.

Monies and Securities:

Checks (Non-Retail):

Other:

4.  Security Provisions

Is an Independent Certified Public Accountant involved in the applicant’s financial reporting?

If yes, are financial statements:    Audited and Reviewed Complied with Recommendations, if any

 Yes

 No

Do you have an Internal Audit Department?

 Yes

 No

Do you have written internal control policies/procedures?

 Yes

 No

Is there a written investment policy or procedure?

 Yes

 No

Do employees who reconcile bank statements also; sign checks, handle deposits, have access to check signing machines?

 Yes

 No

Is your purchasing department separate from the receiving department?

 Yes

 No

Are two signatures required on checks?

If yes, what dollar amount?  If no, who signs checks?  

 Yes

 No

Is there a wire transfer policy or procedures?

 Yes

 No

Is there is a written investment policy?

 Yes

 No

Is there a periodic review by committee or Board?

 Yes

 No

General Liability Information

n/a

Premium

Excess Limit

6 of 3410/23/2007

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