Fidelity Guarantee Insurance Proposal Form 1. Proposer Please select the country/city where the form is to be submitted -Select Country- Kuwait Lebenon Saudi Arabia U.A.E 1 Full name of employer 2 Address 3 Telephone No: 4 Fax No. 5 E-mail Address 6 Period of Insurance required from to 7 Nature of business or trade Year Established 1900-1925 1926-1950 1951-1975 1976-2000 2001 till date Decide whether a Policy on a "named" or "unnamed" basis is more appropriate for your business...then complete either Schedule A or Schedule B 2.Schedule A - to be completed where Employees are to be specified in the Policy by name. Full name and address of the employee to be guaranteed Age Duties Length of Service Salary & other Allowances Amount to be guaranteed 3.Schedule B- to be completed where Employees are to be specified in the Policy by category of employment. Categories of employee to be guaranteed *Maximum number in each category Amount to be guaranteed Blanket basis {(a) to (e) below to be completed if guarantees FOR ALL OF YOUR EMPLOYEES are required} (a) Outdoor staff (salesmen, collectors etc.) with responsibility for money or stock (b) Indoor staff with responsibility for money, securities, or engaged in bookkeeping or accounts. (c) Indoor staff with responsibility for stock only (d) Office Staff with no responsibility for money, stock, book keeping or accounts. (e) All other staff (e.g. manual workers) who do not at any time handle money or have control over stock. Position basis (give details below if you require guarantees for employees in SPECIFIED POSITIONS ONLY)   4. Some general questions 1 Are all employees who normally handle or are responsible for money, stock or accounts included If 'NO' on what basis are they selected for guarantee. select Yes No 2 Do you always obtain satisfactory written character references (direct from former employers where applicable) for the 3 years prior to the engagement of any employee (other than manual workers who neither handle money nor have control over stock)? If 'YES' will such references be retained for a period of at least 3 years and always be available to Compagnie Libanaise d'Assurances during that period? select Yes No select Yes No 3 Have you ever sustained a loss as a result of the dishonesty of any employee If 'YES' give fill details and describe the steps taken to prevent a recurrence select Yes No 4 If cover is required in respect of auditors' fees included in proving a loss please state amount of cover respect of any one claim. 5 Do any of the employees to be guaranteed reside or work overseas ? If 'YES' please give details. select Yes No   5. System of supervision and check 1 What is the largest amount any one employee will hold at any one time of (a) Stock (b) Money 2 In what way and in what form does the money reach the hands of the employees? 3 What form of receipt is provided? 4 (a) At intervals is money received by employees remitted to you or to the bank? (b) How often statements sent to you by the bank? (c) Are bank statements sent to you direct and not via any employee responsibe for banking? select Yes No select Yes No 5 (a) What amounts are employees permitted to retain from money received? (b) For what purpose is such money retained ? (c) What controls are exercised over the amount and use of such money? 6 (a) What procedure is used for recording incoming payments to business? (b) How often are such records inspected and compared with receipt counterfoils, bank statements, stamped bank pay-in slips etc. independently of the employees responsible therefore? (c) Do employees who normally handle money or stock also have duties in connection . with ledgers, stock records etc.? If 'YES' please give details select select Yes No 7 (a) What amount of petty cash is held? (b) Is the 'Imprest' system operated? (c) How often are checks made to establish that the balance is held correct? select Yes No 8 (a) How often are accounts rendered direct to customers independently of employees responsible for collection or receipt of money ? (b) What steps are taken to verify accounts stated to be in arrears ? (c) Is it possible for the employees responsible for collect of receipt of money to interfere with the despatch of reminders select Yes No 9 Has any employee power to draw on the business bank account? (a) What is the Maximum amount of any one cheque on the employee's own signature? (b) Jointly with others select Yes No 10 (a) What is the nature of stock or samples controlled or held by the employees? (b) How are disbursement of such stock or samples recorded ? (c) What system is used for authorizing the purchase of stock and recording deliveries ? (d) How often is such stock or samples physically examined and checked independently of the employees responsible therefor ? (e) What was the date of the last such examination and what was the position disclosed? (f) What other spot checks and examinations are made to verify the correct stock position ? 11 (a) Are the amounts and names included in the wages and salaries sheets checked independently of the employees responsible for their preparation ? (b) How often are unpaid wages and salaries checked independently of the employees responsible therefor ? select Yes No 12 To what extent is your accounting system computerized.?   Declaration: I/We declare that: There has never been occasion to question the honesty or good conduct of any of the persons to be guaranteed. No Insurer has ever cancelled or refused to renew any insurance or declined to insure me/us or required special terms. I/We keep proper books of accounts which are regularly examined by professional accountants. I/We are not at present insured with this or any other Insurer of the insurance now proposed. If any of these statements do not apply to you, please give brief reasons here: To the best of my/our knowledge and belief the answers given in this proposal are true and complete and if any answer has been give by any person other than myself/ourselves that person shall be my/our agent for that purpose No material fact has been omitted. I/We agree that this proposal and declaration, together with any correspondence relative thereto, shall be the basis of the contract between me/us and Compagnie Libanaise d' Assurances s.a.l. I/We will accept a policy in the form issued by the Company for the insurance now proposed.     [ To download the form please right click the Download button and select "Save target as" and Save.]  Download the Form              Download Acrobat Reader Top