Ficke & Associates


Background Information
Background Information
Producer Name and Address *
Street Address
ZIp *
Zip Code
Eligibility Financial Institution
Not for Profit
Name Insured
Name Insured
Street Address
ZIp Code
Year Business was Established
Description of Applicant's primary Products
Predominant SIC Code
Billing Options Agency Bill
Billing Options (direct bill)
Premium Payment Options
Three Year Prepaid
Three Year Equal Installments
Coverage Information
Coverage Information
Coverage Effective From
Coverage Limits and Deductibles
Required Coverage
Limits Required $100,000
Optional Policy Coverages G- Extortion
H- Claims Expense
J- Lesses of Safe Deposit Boxes
K- Guest Property-Safe Deposit
L- Guests Property -Premises Legal Liability
N-Faithful Performance
P-Gov't Employee Dishonesty
Effective Date of Coverage
Please describe the Services you offer breifly
Internal Controls and Physical Security
Internal Controls and Physical Security
Internal Controls Do you have an Annual Audit prepared by an Independent CPA
Does the Audit contain a going concern Qualification?
Do you have a CPA review, CPA Compliation or internally prepared Financials?
Do you conduct a prior Employment check on all new Employees ?
Do you conduct a Criminal Background check on all Employees?
Do Purchase Require the Signed Approval of two or more Employees Yes for all purchases  No
Are Purchasing Duties separated so that one Employee may not do more than on of the following 1) Initiate a purchase request 2)Prepare a check voucher 3)Sign checks 4)Mail Vendor Payments Yes  No
Is supporting Documentation for Incoming and Outgoing Shipments initialed as correct before they are Accepted or sent out yes  no
Are Vendor Payments Randomly Audited by an Employee not part of the Vendor Approval or Purchase Approval Process yes  no
On their return must Employees Account for all delivery items with a signed Customer receipt or the Undelivered Item yes  no
On if yes the maximum value is $
Do you have a high value of Cash,Precious or Semi Precious Metals or Stones(such as Gold ,Silver ,Platinium ,Diamonds ) or other valuable ,easily concealed Property (such as Computer Chips ,Electronics,valuable Watch or Jewelry) yes  no
Is there a Fence separating parking areas from any restricted access areas ? yes  no
Is there a fence ,wall or vault to create a restricted area for high value property/cash yes  no
Are restricted acess areas protected by motion Detectors and Central Station Alarms yes  no
Financial Information
Financial Information
Total Assests
Netincome $
Net Loss $
Claims History
Claims History
Claim Discovery Date
Claim Amount
Amount Recovered from Insurance
Claim Circumstances and Corrective Actions
* = Required Field


271 Route 46 West ,Suite A201
Fairfield, NJ 07004
Phone: 1-877-516-3749    
Fax: 1-888-717-776
Click Here for Email
Click Here for Directions

Windsor Business Park
186 Princeton Hightstown Road
Building 3A, Suite 9
West Windsor NJ 08550
Phone: 1-877-516-3749    
Fax: 1-888-717-7763
Click Here for Email
Click Here for Directions

300 E Royal Lane
Suite 116
Irving, TX 75039
Phone: 1-877-516-3749
Fax: 1-888-717-7763
Click Here for Email
Click Here for Directions

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