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False Pretense Fraud Supplemental Application

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False Pretense Fraud Supplemental Application HANOVER False Pretense Fraud Supplemental Application Underwritten by The Hanover Insurance Company I. APPLICATION INSTRUCTIONS Whenever used in this Application, the term "Applicant" shall mean the Named Insured and all subsidiaries or other organizations applying for coverage, unless otherwise stated. II. GENERAL INFORMATION 1. Name of Applicant: 2. Address of Applicant: City: State: Zip Code: Telephone: 3. Does the Applicant provide any financing in the course of its business including leases Yes No or loans to customers? 4. Does the Applicant operate a financial institution, advisor, bank escrow company, Yes No collections agency or similar business? 5. Does the Applicant operate any gaming establishment, armored car service, messenger Yes No service or other operations which involve the transport of money or securities? 6. Does the Applicant have a procedure in place to verify new customers or clients prior to Yes No initiating any financial transaction with them? a. D&B or other credit check? Yes No b. Bank account verification? Yes No c. Confirmation of physical address? Yes No d. Other: Yes No 7. Does the Applicant accept funds transfer instruction from clients over the telephone, Yes No email, text message or similar method of communication? If “Yes” are such instructions authenticated? Check all that apply: Yes No a. Calling the customer at a predetermined number? Yes No b. Sending a text message to a predetermined number? Yes No c. Requiring receipt of a code known only to the customer to confirm identity? Yes No d. Other: 8. Does the Applicant allow prepayment by customers or clients for products or services to Yes No be performed at a later date? 9. Does the Applicant have a procedure to verify incoming checks with the issuing financial Yes No institution to confirm funds are available prior to performing services or transferring money? 10. Does the Applicant have custody or control over any funds or accounts of any of its Yes No clients, including but not limited to escrow or trust accounts? If “Yes” please attach a description of such accounts. Form 904 7034 APP Ed. 01/15 Page 1 of 4 HANO VER False Pretense Fraud Supplemental Application 11. Do the Applicant’s employees have access to clients’ accounting, payroll, purchasing Yes No systems or bill payment systems? 12. Does the Applicant verify all vendor or supplier bank accounts by a direct call to the Yes No receiving bank prior to being established in the accounts payable system? 13. Does the Applicant confirm all changes to vendor and supplier details by a direct call Yes No using only the contact number previously provided by the vendor/supplier before the request was received? If “Yes” do such details include routing numbers, account numbers, telephone numbers Yes No and contact information? 14. Are confirmations of changes requested by a vendor or supplier to a person Yes No independent of the requestor of the change, with any changes being implemented only after the vendor/supplier has the opportunity to challenge them? 15. Does the Applicant review all changes to vendor or supplier records by a supervisor or Yes No next-level approver before any change to the record is processed? 16. Does the Applicant run exception reports, either automatic, or manually created showing Yes No all changes to the standing data of vendors and suppliers? If “Yes” how often are the reports run and by whom are they reviewed? 17. Does the Applicant have contractual agreements that all vendors or suppliers purchase Yes No and provide evidence of crime or fidelity insurance covering the Applicants money or securities when it is in the vendors care, custody or control? 18. Who has the authority to initiate a wire transfer? 19. Can wire transfer authority be delegated to anyone verbally or in writing? Yes No 20. If online banking software is used to perform wire transfer functions, is access to the Yes No portal restricted to specific users and terminals? 21. Are finance employees that are responsible for wire transfers provided anti-fraud Yes No training, including detection of false pretenses, social engineering, phishing or other confidence scams? 22. Are international and domestic wire transfer procedures performed consistently across Yes No all business units? III. LOSS EXPERIENCE Has the Applicant had any employee theft, burglary, robbery, forgery, computer fraud or Yes No other crime losses which were discovered in the last five years? If “Yes” please attach a list of such losses itemizing each loss separately, date of loss, description and total amount of loss. IV. NOTICE AND SIGNATURES NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. NOTICE TO ARIZONA AND MISSOURI APPLICANTS: Claim Expenses are Inside the Policy Limits. All claim expenses shall first be subtracted from the limit of liability, with the remainder, if any, being the amount available to pay for damages. Form 904 7034 APP Ed. 01/15 Page 2 of 4 HANO VER False Pretense Fraud Supplemental Application NOTICE TO ARKANSAS, LOUISIANA AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provide false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. NOTICE TO IDAHO AND OKLAHOMA APPLICANTS: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO KANSAS APPLICANTS: Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A fraudulent insurance act means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to, or by an insurer, purported insurer or insurance agent or broker, any written statement as part of, or in support of, an application for insurance, or the rating of an insurance policy, or a claim for payment or other benefit under an insurance policy, which such person knows to contain materially false information concerning any material fact thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto. NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. NOTICE TO MAINE, TENNESSEE, VIRGINIA, AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MICHIGAN APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent act, which is a crime and subjects the person to criminal and civil penalties. NOTICE TO NEW JERSEY APPLICANTS: Any person who knowingly includes any false or misleading information on an application for an insurance policy or files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. NOTICE TO NEW MEXICO AND RHODE ISLAND APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
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