Fidelity Guarantee Insurance Proposal Form 1Tell us about you2Give us details of the cover3Individual Cover4Floater Cover5Cover involving cash6Cover involving stock7Declare this proposal PROPOSER'S DETAILSName(Required) First Last Address(Required)Occupation Insurance Period of Insurance Start Date(Required) DD slash MM slash YYYY Insurance Period of Insurance End Date(Required) DD slash MM slash YYYY COVER DETAILSTick all appropriate parameters of the cover below(Required) Individual Cover Floater Cover Involves Cash Involves Stock DETAILS OF EMPLOYEE (S) TO BE INSUREDList of employees(Required)Add information into each column and press (+) to add another rowNameDutiesYear of EmploymentLimit Per OccurrenceAggregate/Annual Limit Add Remove FLOATER COVER DETAILSNumber of Employees to be covered(Required)Annual Turnover(Required)Limit of Liability/ Total amount to be insured(Required)Collusion Limit if anyIs there a system to obtain references from previous employer?(Required) Yes No Specify practice followed(Required)The maximum amount held by any employee at any one in time(Required)How long is this amount held? (In days)(Required) CASH & PAYMENT DETAILSHow often are the employees required to account for money? Do employees pay out money or draw cash from proposer’s account?(Required) Yes No If yes, are such payments/withdrawal authorized by a senior employee?(Required) Yes No How often is the cash book balanced, the entries checked with vouchers and other Bank’s documents?(Required) STOCK DETAILSWhat is the system followed for purchase, authorizing dispatch, ensuring dispatch and recording deliveries of goods?(Required) How often and by whom stock verification is done?(Required) What is the extent and frequency of audit?(Required) Details of losses suffered on account of infidelity of any employee in the last five years.(Required) Has any company decline, cancelled, refused or accepted you proposal on special terms and conditions?(Required) Yes No Claims ExperienceYearPremiumIncurred LossesLoss Ratio Add Remove DECLARATIONDate DD slash MM slash YYYY Declaration I hereby declare the below statementI/We to the best interest of my/our knowledge hereby confirm that the statements contained in this proposal form are true and correct and I/We have not concealed, misrepresented or misstated any material fact. I/We agree that the statements and declaration contained in this proposal form shall be the contract of insurance with the company and are deemed to be incorporated in the contract.
