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FIDELITY GUARANTEE INSURANCE - CLAIM FORM (The issue of this form does not constitute admission of liability. Please return the form duly completed within three months of the discovery of the loss together with all the particulars annexures). Policy No. Claim No. 1. a) Name of nsured (in full) b) !ddress c) "usiness #. a) Name of the defaulting employee in full b) $is present address %. !mount of loss sustained '. (ate of discovery of the defalcation ). (ate (s) of defalcation *. $ow exactly was the defalcation committed+ f space is not sufficient, please give full and detailed particulars on a separate signed sheet. (!lso please attach a certified statement containing all entries in the nsured-s boo.s of accounts relative to the defalcation in the order of their dates) a) b) c) a) b) &s.


Please reply fully to the following 0uestions regarding the duties of the employee at the time of defalcation12 a) n what capacity was he engaged and where+ 3oney b) n what way did money reach his hands+ c) 4hat was the largest sum which he held in his hands at any one time and for how long+ d) 4as he allowed to pay out any amounts on the nsured-s behalf+ f so, details e) 4ho authorised these payments or issues+ f) 4as he re0uired to give printed receipts from a boo. with counterfoils+ f so, how often were the counterfoils examined and chec.ed and by whom+ g) 4ere moneys paid into "an. by the defaulting employee+ f so, how often were "an. "oo.s examined and chec.ed and by whom+ h) 4hat balance, if any was allowed to be .ept in his hand+ i) $ow often were the Cash !ccounts balanced and how was their accuracy chec.ed+ Please explain fully. 5) $ow often were accounts sent direct to Customers independently of the employee+ 6toc.

a) b) c) &s. d) e) f) g) h) &s. i) 5)

.) .) (id the employee have charge of stoc.+ f so, in what way did stoc. reach his hands+ l) l) 4as he allowed to issue stores or materials independently+ f not, who m) authorised these issues+ m) $ow often was the position of stoc. handled by the employee chec.ed+ n) n) 4hen was the last chec. made+ 7. $ow often were the !ccount "oo.8 6toc. "oo.s at the place of the defaulting employee-s employment audited and by whom+ 4hen was the last audit done+ 9. $as the nsured any moneys, estate, or effects of the employee in his possession+ f so, give particulars with amounts. 1:. (oes the nsured hold any other security from the employee+ f so, state its nature and amount. 11. s the defaulting employee a member of a 5oint family, or does he hold any property, furniture or other effects+ f so, give details. 1#. $as the employee any near relatives+ f so, give their names and addresses, if .nown. 1%. $as the nsured ta.en any action against the employee+ f so, state the nature of action ta.en. 1'. $as the loss been reported to the Police+ f so, state at which Police 6tation and what action, if any has been ta.en by them. 8 4e hereby declare that the foregoing particulars are true and correct in every respect. Place 1 (ate 1 Sign !"#$ %& In'"#$() 4itness1