ACORD 141C Instructions

Use this form to apply for Crime coverage to companies that have adopted the 2000 ISO Crime Program.

Use this form in conjunction with the Commercial Insurance Application, Applicant Information Section, ACORD 125. Refer to the chapter on ACORD 125 for information on that form.

Note that ACORD 141, Crime Section, and ACORD 151, Miscellaneous Crime Coverage Section, should continue to be used with companies that have not yet adopted the new ISO program.

COVERAGE /LIMIT/DEDUCTIBLE

Use this section to indicate the coverage form or forms that is/are being applied for, the applicable limit(s), and deductible(s), if any.

Employee Theft
Indicate if the risk is to be written on a blanket or scheduled basis, and if ERISA coverage is to be included, and provide the total asset value according the the manual rules.

Employee Theft Government Crime
Indicate if the risk is to be written on a blanket or scheduled basis, and if coverage is to be provided on a "per loss" or "per employee" basis.

Forgery or Alteration
Enter the limit and the deductible only.

Inside The Premises
Check the appropriate boxes to indicate coverage for Theft of Money and Securities (blanket or schedule), and/or Robbery or Burglary of Other Property (blanket or schedule).

Outside The Premises
Check the appropriate boxes to indicate coverage for Money and Securities and/or Other Property (blanket or schedule).

Computer Fraud
Enter the limit and the deductible only.

Funds Transfer Fraud
Enter the limit and the deductible only.

Money Orders and Counterfeit Paper Currency
Enter the limit and the deductible only.

COVERAGE ENDORSEMENTS

There are many endorsements available. Refer to the ISO Commercial Lines Manual, the Surety Manual, or your company's manual for a complete description of each endorsement and their rules of use, as well as pertinent rating and underwriting information needed for each form.

ERISA EMPLOYEE THEFT ADDITIONAL INFORMATION

Show the name of each plan, principle address, number of trustees or employees handling the plan assets, and the number of plan participants. If more than one plan, provide the necessary information for each plan separately.

GENERAL INFORMATION

Use the Remarks section to provide additional information for any questions answered with a "yes" response.

1. Are volunteers used? If yes, how many?
Number of volunteer employees.

2. Any employee leased to others?

If yes, give the number and explain in Remarks.

3. Any employees leased from others?

If yes, give the number and explain in Remarks.

4. Any employees perform money investing or trading?
If yes, provide the number of employees involved in these transactions, and the controls provided by management.

5. Any employees receive or issue warehouse receipts?
If yes, provide details.

6. Any employee(s) been cancelled for crime coverage by any insurer?
If yes, provide name of employee(s) and reasons for cancellation.

7. Does applicant have any written agreements with clients?
If yes, describe the type of agreements.

8. Does applicant transfer any funds by phone or fax?
If yes, provide details, including the dollar amounts transferred, and the organizations to whom the funds are transferred, and the frequency of the transfers.

9. Any exposure from loss to guest property?
If yes, provide details.