Name Of Council or Troop:
District, Council or Troop Number:
Your Street Address:
City: ST: Zip:
Contact Person:
Email: URL:
Phone: FAX:

Coverage A - Employee Dishonesty: $ 5,000 limit / $ 100 deductible $10,000 limit / $ 100 deductible $15,000 limit / $ 250 deductible $25,000 limit / $ 500 deductible $50,000 limit / $1,000 deductible

Coverage B - Forgery or Alteration (Cannot exceed limit selected under Coverage A): $ 5,000 limit / $ 100 deductible $10,000 limit / $ 100 deductible $15,000 limit / $ 250 deductible $25,000 limit / $ 500 deductible $50,000 limit / $1,000 deductible

Coverage C - Inside and Outside Premises and Messenger: $ 2,500 limit / $ 250 deductible $5,000 limit / $ 500 deductible
Internal Controls: Are the financial procedures, as recommended, currently being adhered to in their entirety? Yes No

Loss Experience: List all crime losses you have suffered in the last 3 years: Check if none. Date: Amount of Loss: Description of Loss(es):
Number of Officers
Number of regular Volunteers who frequently handle money In order to respond quickly we request that all the fields be completed.