Employee Fidelity Bond Application - Alliance for Contractors

APPLICANT COMPANY INFORMATION

Company Name:

Business Address:

City, State, ZIP:

Phone: Email:

Federal Tax ID: Years in Business:

Type of Construction Business:

Annual Gross Revenue: Number of Employees:

COVERAGE DETAILS AND AMOUNTS

Select desired coverage amounts (check all that apply):

Coverage Type	Coverage Amount	Annual Premium
Basic Employee Dishonesty	$25,000	$_________
Standard Employee Dishonesty	$50,000	$_________
Enhanced Employee Dishonesty	$100,000	$_________
Premium Employee Dishonesty	$250,000	$_________
Executive Employee Dishonesty	$500,000	$_________
Computer Fraud Coverage	$_________	$_________
Funds Transfer Fraud	$_________	$_________
Money Orders/Counterfeit Currency	$_________	$_________

Preferred Deductible Amount:

$1,000

$2,500

$5,000

$10,000

Other: $_______

EMPLOYEE INFORMATION AND SCREENING REQUIREMENTS

Employee Category	Number of Employees	Background Check Required	Financial Access Level
Executive Management	_______	Yes No	High Medium Low
Office/Administrative Staff	_______	Yes No	High Medium Low
Accounting/Finance Personnel	_______	Yes No	High Medium Low
Project Managers/Supervisors	_______	Yes No	High Medium Low
Field Workers/Technicians	_______	Yes No	High Medium Low
Temporary/Seasonal Workers	_______	Yes No	High Medium Low

Alliance Screening Integration Services (Optional)

Criminal Background Checks

Credit History Verification

Employment History Verification

Reference Checks

Drug Testing Coordination

Professional License Verification

RISK ASSESSMENT QUESTIONS

Question	Yes	No	Comments
Has your company experienced employee theft in the past 5 years?			_________________
Have you had previous fidelity bond coverage?			_________________
Do employees handle cash, checks, or valuable materials?			_________________
Do employees have access to company credit cards or accounts?			_________________
Are employees authorized to make purchases on behalf of the company?			_________________
Do you conduct regular inventory audits?			_________________
Are financial records kept electronically?			_________________

LOSS PREVENTION MEASURES

Current Security Measures in Place (Check all that apply):

Security cameras/surveillance system

Alarm system with monitoring

Access control systems

Safe/vault for cash and valuables

Background checks for all employees

Regular financial audits

Dual approval for large expenditures

Segregation of financial duties

Regular inventory controls

Employee handbook with theft policies

Annual employee training on ethics

Whistleblower reporting system

Alliance Loss Prevention Services (Optional):

Security assessment consultation

Internal controls development

Employee training programs

Audit procedures implementation

Policy and procedure review

Incident response planning

INTERNAL CONTROLS AND ASSET PROTECTION

Financial Controls:

Bank Account Reconciliation Frequency:	Daily Weekly Monthly
Check Signing Authority:	Single signature Dual signature required
Purchase Order System:	Yes No
Expense Approval Process:	Formal process Informal review
Petty Cash Controls:	Yes No N/A

Asset Protection Measures:

Equipment/Tool Inventory Value: Inventory Method:

Materials/Supplies Value: Storage Security Level:

Vehicle Fleet Value: GPS Tracking: Yes No

PREMIUM CALCULATION AND PAYMENT

Base Premium (calculated by underwriter):	$____________
Risk Assessment Adjustment:	$____________
Loss Prevention Discount:	-$____________
Alliance Member Discount (10%):	-$____________
Total Annual Premium:	$____________

Payment Options:

Annual payment (5% discount)

Semi-annual payments

Quarterly payments

Monthly payments (processing fee applies)

TERMS AND CONDITIONS

Coverage Effective Date: Coverage begins on the date specified above and continues for the policy period, subject to premium payment and acceptance by the insurance carrier.

Reporting Requirements: Any suspected employee dishonesty or theft must be reported to Alliance for Contractors within 24 hours of discovery. Failure to report promptly may affect coverage.

Investigation Cooperation: The insured agrees to cooperate fully with any investigation of claimed losses, including providing access to records, personnel, and premises as required.

Loss Prevention Compliance: The insured agrees to maintain the loss prevention measures identified in this application and to implement additional measures as recommended by Alliance for Contractors.

Employee Changes: The insured must notify Alliance for Contractors of significant changes in employee count, responsibilities, or access to company assets within 30 days.

Background Check Integration: If Alliance screening services are selected, the insured authorizes Alliance for Contractors to coordinate background checks and share results with the insurance carrier for underwriting purposes.

Warranty: The applicant warrants that the statements made in this application are true and complete and agrees that this application shall be the basis of any insurance contract issued.

Applicant Signature

Print Name: _____________________

Title: ___________________________

Date: ___________________________

Alliance Representative

Print Name: _____________________

Title: ___________________________

Date: ___________________________

FOR OFFICE USE ONLY

Application Received: __________ Reviewed By: __________ Approved: __________ Policy Number: __________

Alliance for Contractors | Employee Fidelity Bond Division
Protecting Your Business, Securing Your Future