Lodge Name
Lodge Number
Name
Address
City
State	Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific Guam Northern Mariana Islands Puerto Rico United States Virgin Islands
Zip Code
Phone
Fax
E-mail

Are at least two signatures required on checks?	Yes No
Do employees who reconcile monthly bank statements also sign checks?	Yes No
Do employees who reconcile monthly bank statements handle bank deposits?	Yes No
Do employees who reconcile monthly bank statements have access to check signing machines or signature plates?	Yes No
Is an Independent Certified Public Accountant involved in the applicant's financial reporting?	Yes No
Has any similar Fidelity insurance been declined or cancelled during the past three years?	Yes No
Have there been any losses discovered or sustained in the last three years?	Yes No
Is similar coverage currently in place?	Yes No

Limit and Deductible Options

	Limit*	Deductible	3-Year Prepaid Premium
			(Kentucky lodges must add 1.5% surcharge.)
	$25,000	$250	$308
	$50,000	$500	$435
	$100,000	$1,000	$605
	$200,000	$2,000	$734
	$300,000	$3,000	$861

Premium is considered fully earned at coverage inception.
*Limits requested over $25,000 are subject to additional underwriting requirements.

Payment Methods: Credit Card or Check.

Requested Effective Date

Signature Date Signed

Notes

After review of your application you will receive an email with payment instructions. Coverage effective dates are the first day the application is approved and payment is received by Hylant.

The Fidelity Bond Liability Program is not a plan offered or covered by FOP Legal Plan, Inc. The Fidelity Bond Program is offered and insured by an outside independent insurance company and is endorsed by The Grand Lodge FOP.