NAVREF Insurance Program - Application for Crime+ Policy<$1 million

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CRIME PLUS+ POLICY

Travelers Property Casualty

A member of Travelers Group

NAVREF Program Application (Limits of $1 million or less)


Name	_______________________________				SIC code	________	Agent	P. Allen Haney Co,
(If more than one Insured, please attach a list)							Agent Code	____________________

Address	______________________________________________________________________________________ ______________________________________________________________________________________
City	__________________		State	_________	Zip	________	Effective Date	___________________

Predominant Business Activity			__________________________________				Billing	___________________
Year Business Started		_________		Annual Sales or Revenue		________		Installment	Prepaid

Desired Coverage		Limits of Liability
If all six basic Insuring Agreements are desired at the same Limit:		________________________________
or, if varying Limits or Insuring Agreements are desired:		________________________________
Insuring Agreement I: Employee Dishonesty		________________________________
Insuring Agreement II: Forgery and Alteration		________________________________
Insuring Agreement III: On Premises		________________________________
Insuring Agreement IV: In Transit		________________________________
Insuring Agreement V: Money Orders and Counterfeit Paper Currency		________________________________
Insuring Agreement VI: Computer Fraud and Funds Transfer fraud		________________________________
Other:		________________________________
Deductibles:
Prior Insurer:_________	Limit:_________	Deductible:_________	Premium: ____$405___

Loss Experience:

List all crime losses sustained during the last three years whether reimbursed or not. Check here if none

Date of Loss

Total Amount of Loss

Description of Loss and Corrective Action

______________________________________________________________________________

Number of Employees*	US/Canada		Other Countries		Total

Locations (other than main office)		______________		______________		______________

*Also includes the following:	*Leased*	______________	*Temporary*	______________	*and Non-compensated Employees*	______________

Companies that practice segregation of duties and perform background checks on new employees have a better opportunity to either prevent or detect employee dishonesty. Segregation of duties means that no single employee can control a process or transaction from beginning to end.

1. Are officer-shareholders active in the day to day operation of the business?		Yes	No
2. Do employees who reconcile the bank statement also:
	Make deposits:	Yes	No
	Make withdrawals:	Yes	No
	Sign checks:	Yes	No
3. Is a CPA involved in the applicant's financial reporting:		Yes	No
4. For new employees, are background checks which may included prior employment, criminal history or drug testing performed?		Yes	No

Please indicate maximum exposure for each location:

*Locations*	*Cash*	*Retail Checks*	Credit Card Receipts and Non-retail Checks*	Is there a Safe? (Y or N)
______________________________________________________________________________

*A non-retail check is a check presented to you and immediately endorsed "for deposit only" and then recorded in your accounting process so that it could be recreated if it were stolen, lost or destroyed.

The reverse of this application includes important information regarding insurance fraud. Please read the Fraud Statement on the reverse before signing this application.

Date___________________ Signature__________________________ Title______________________________

F-3190 (1/97)

last updated: 01/31/08