State of Florida Crime Policy Application For Governmental Entities

Transcription

1 Additional locations are provided on the Crime Schedule attached hereto. 2 Yes No Yes No 4. Internal Controls Yes No Bank Accounts a. Are bank accounts reconciled monthly? b. Are bank accounts reconciled by someone not authorized to deposit, withdraw, or write checks? Checks and Securities c. Is countersignature of all checks required? Above what amount? d. Do all vouchers or other supporting records accompany all checks to be signed? e. Are vouchers/supporting records stamped PAID when checks are signed? f. Are controls set up to prevent unauthorized use of check signing machines and/or signature stamps? g. Are your systems designed so that no single employee can control a transaction from beginning to end (e.g. approve a voucher, request and sign a check?) h. Are securities subject to the joint control of two or more employees? i. Is a positive pay system used? Payroll j. Do you screen your employees for prior acts of dishonesty? If not, which departments employ those without background checks? k. Do you use drug free workplace programs? l. Is the payroll made up by persons other than those who distribute it to employees? m. Are all persons who are authorized to hire and/or fire emplo yees prohibited from distributing the payroll? n. Is positive identification required of each person receiving pay? o. Do you have employees acting in the capacity of an in house claims adjuster? Purchasing and Inventory p. Are all persons engaged in purchasing prohibited from taking part in receiving the inventory? q. Are all shipping and receiving activities reconciled to all applicable sale or purchase orders? r. Does any employee have access to the purchasing system and also the accounts payable system? s. Do you have a system to detect payment to fictitious suppliers? t. Do you verify tax ID numbers for all vendors? u. Is a complete inventory made with physical check of stock and equipment? 5. Funds Transfer Procedures Yes No a. What departments conduct wire transfers? We do not do wire transfers b. Do you maintain a fully documented procedure manual covering all wire transfer procedures? N/A c. Are all payment instructions executed under a sequential numbering system? N/A d. Is there an internal audit department which includes E.D.P. auditing? e. If there is no internal audit department, please advise how this function is fulfilled: f. If you utilize consultants, do you change passwords when they finish their work? N/A g. What is the total annual volume of funds transferred? N/A h. What is the largest amount one person can transfer? N/A i. What is the average size of transfers? N/A

2 j. Are all funds transfer functions handled by banks and/or institutions? N/A k. Do you have facilities to transfer funds yourself without involving third parties? N/A 5. Funds Transfer Procedures (continued) l. Are all telephone transfer instructions given to banks confirmed in writing within 24 hours? N/A m. Is there segregation of duties so that no one employee can initiate and complete transactions without approval by others? N/A n. Do you change passwords when employees leave? N/A o. Describe controls in place to prevent unauthorized use of computers by employees or others (i.e. are computer rooms locked, maintenance ports protected, etc.)? N/A p. What is the total number of employees who have the authority to make transfers? N/A q. Do you utilize port security that detects unusual activity? N/A r. How do you detect whether an employee has exceeded their authority? N/A 6. Vendor Information Yes No a. Are background checks performed on vendors in order to determine ownership and financial capability prior to doing business with them? b. Is an authorized vendor list utilized and updated for all annual purchases, with competitive bidding required over stated amounts? c. Are requisitions and purchase orders issued only after the approval of specified personnel within specified limits? d. Is each cash disbursement based on a recognized liability, accurately prepared, and appropriately authorized, including comparisons to authorized vendor lists and receiving reports? e. Are perpetual inventories maintained of materials and supplies and periodically verified by physical count? f. Are vendors provided with a statement of your conflict of interest and gift policy (prohibiting gifts of any significant value)? g. Are vendors asked to disclose any gifts or favors offered or requested or other questionable behavior by employees? h. Do the same controls apply to locations outside of the United States? 7. Prior Insurance Yes No a. Has any similar insurance been declined or canceled during the past three years? If yes, please explain b. Prior insurance to be superseded Check here if none Form of Insurance Effective Date Expiration Date Government Crime State of Florida 01/01/ /01/2015 Limit of Insurance Refer to Policy # CCP Name of Insurance Company Fidelity & Deposit Company 8. Loss History Enter all claims or occurrences whether or not paid that may give rise to claims for the prior 5 years. Check here if none Date of Occurrence Type/Description of Occurrence or Claim NONE Date of Claim Amount Paid Claim Status Open Closed 3

3 8. Loss History (continued) Comments/Corrective Action Taken: NONE 9. Classification of Employees and Locations Grand total of ALL employees: 4050 # of CLASS PLEASE ATTACH TOTAL EMPLOYEE CENSUS BY DEPARTMENT Note: Persons required by law to be individually bonded and treasurers or tax collectors by whatever titles know are automatically excluded. If insurance is desired on any of your appointed or elected agents please complete the following: Capacity in Which Each Agent Serves 10. Money - Securities Which locations require Money and Securities Coverage? $ $ $ $ Limit of Insurance Type Inside Messenger #1 Messenger #2 Money Securities (other than Payroll Checks) Checks (Excluding Retail Checks) 4 Payroll Checks Money Overnight Securities (In Bank/Safe Deposit) Please advise if you need to temporarily increase the above limits for what departments and for what timeframe. 11. Premises/Safe Protection We have safes at each location. Details not available at this time. a. What type of alarm(s) do you have at each of your premises? Hold-up Alarm Premises Alarm Safe Alarm Local Gong Central Station Alarm Police Connected Alarm If alarms vary from location to location, please explain: They vary details not available at this time. b. Please specify the number of guards and/or watchpersons on duty each shift: 0 c. Please describe any additional protection (e.g. fences, floodlights, etc.): Unknown at this time 12. Internet Security Yes No a. Do you buy or sell goods via the internet? b. Do you have a firewall? c. Do you have an intrusion detection system that identifies unauthorized access? d. Do you have documented internet guidelines for employees? e. Do you have documented emergency procedures? f. Has your computer system ever been invaded by a hacker or virus? Virus If yes, when and what controls have been implemented to prevent further incidences? We use McAffee virus scan and have a section that identifies viruses.

4 13. Food Stamp Procedures We do not have a Food Stamp Program Yes NoXX Please complete this section if your organization handles Food Stamps, Vouchers or Debit Cards a. Where is the bulk supply of food stamp coupons or debit cards stored? Who has access to this storage area? 13. Food Stamp Procedures (continued) b. How often are they inventoried? Who has the ability to secure the coupons? c. Are those employees specifically responsible for issuance restricted from access to storage and issuance areas? d. How do you distribute food stamps or debit cards to recipients? e. How are coupons secured for transit? Are they stored in a locked container? Who is responsible for transit? f. When are they activated and by whom? g. If a card is reported lost or stolen, how are they replaced? What controls are in place to prevent duplicates from being issued? h. Safe/Vault Manufacturer Label Door Type Combination Locks Thickness UL/SNMA Class Round Square Outer Inner Chest Door Wall NOTICE TO 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. Applicant Signature: Wayne E. Glembin Title: Property and Insurance Supervisor Date: Sept 23, 2014 Please submit the Crime ITB Excel workbook with along with this application. 5

5 Department of Revenue (DOR) Location Detail Limits Inside, Per Location Limits Outside, Per Location Location Department Cash Checks Cash Checks Number of Locations Description Address DOR $ 10,000,000 $ 10,000,000 $ 10,000,000 $ 10,000,000 1 Central Ops Ctr 5050 West Tennessee Street, Tax World L Tallahassee FL DOR $500,000 $500,000 $500,000 1 Jacksonville GTA Service Center 921 N. Davis Street, Suite A-250 Jacksonville FL DOR $500,000 $500,000 $500,000 1 Orlando GTA Service Center 400 W. Robinson Street, Suites 300 & 500 Orlando FL DOR $500,000 $500,000 $500,000 1 Miami GTA Service Center 8175 NW 12th Street, Suite 119 & 418 Miami FL DOR $500,000 $500,000 $500,000 1 Tampa GTA Service Center 6202 E. Martin L. King Jr Blvd, Suite 100 Tampa FL

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11 Department of State (DOS) Location Detail Limits Inside, Per Location Limits Outside, Per Location Location Department Cash Checks Cash Checks Number of Locations Description Address DOS $ 50 $ 2,000,000 $ 50 $ 2,000,000 1 Office 2661 Exec. Ctr. Cir., Clifton Building Tallahassee FL DOS $ - $ 100 $ - $ Office 1001 Desoto Park Dr., Tallahassee FL DOS $ 850 $ 1,700,000 $ 850 $ 1,700,000 1 Office 500 S Bronough Street, Rm 428 Tallahassee FL DOS $ - $ 30,000 $ - $ 30,000 1 Office (Cultural Affairs) 329 N Meridian St. Tallahassee FL 4

12 Agency or University making application: Florida Department of State Principal address: 500 S. Bronough St. City: Tallahassee State: FL. Zip: Any excluded entities: Policy Effective Period 1/1/2015, 12:01 am To 1/1/2016, 12:01 am 1. Insuring Agreement Limit of Insurance Deductible 1. Employee Dishonesty $ 500, $ 10, Forgery or Alteration $ 0.00 $ Inside Premises $ 2,000, $ 10, Outside Premises $ 3,731, $ 10, Computer Fraud $ 0.00 $ Money Orders and Counterfeit Paper Currency $ 0.00 $ Funds Transfer Fraud $ 0.00 $ Faithful Performance Coverage Yes No If Faithful Performance of Duty is requested, please cite statutory provision or indicate None 2. Coverage Amendments (Endorsements) Yes No a. Is Kidnap, Ransom, and Extortion coverage desired? (separate application required) b. Description of your organization: State Agency Other c. Is Insurance being provided for a State college or university? d. Description of operations for covered entities: State Government e. Do you receive payments via the internet? (If yes, please compete the Internet Security Section 12 of this application) 3. Audit Procedures Yes No a. Is there an annual audit complete by a: State Agency Public Accountant If yes, how frequently? Quarterly Semiannually Annually b. Does the state auditor conduct an audit annually or on a surprise basis? c. Are all departments and agencies audited? The Department of State is. d. Does the auditor have the authority to check any record at any time? e. If weaknesses are discovered, to whom does the auditor report to for corrections? Department Management f. Date of completion of last audit: State CPA g. Do you audit your wire funds transfer procedures? h. Do you audit the usage of grant funds? i. Please list your divisions/locations that accept cash payments (Ex: DMV, licensing and permit agencies, toll collections, etc.) Division / Locations 1 Computerized Audited Annually Dept. of State /500 S. Bronough St., Rm. 428, Tallahassee Yes No Yes No Corporations/2661 Exec. Ctr. Cir., Clifton Bldg., Tallahassee Yes No Yes No Historical Resources/1001 Desoto Park Dr., Tallahassee Yes No Yes No Cultural Affairs/329 N. Meridian St., Tallahassee Yes No Yes No

13 Additional locations are provided on the Crime Schedule attached hereto. 4. Internal Controls Yes No Bank Accounts a. Are bank accounts reconciled monthly? b. Are bank accounts reconciled by someone not authorized to deposit, withdraw, or write checks? Checks and Securities c. Is countersignature of all checks required? All Above what amount? All d. Do all vouchers or other supporting records accompany all checks to be signed? e. Are vouchers/supporting records stamped PAID when checks are signed? f. Are controls set up to prevent unauthorized use of check signing machines and/or signature stamps? g. Are your systems designed so that no single employee can control a transaction from beginning to end (e.g. approve a voucher, request and sign a check?) h. Are securities subject to the joint control of two or more employees? i. Is a positive pay system used? Payroll j. Do you screen your employees for prior acts of dishonesty? If not, which departments employ those without background checks? k. Do you use drug free workplace programs? l. Is the payroll made up by persons other than those who distribute it to employees? m. Are all persons who are authorized to hire and/or fire employees prohibited from distributing the payroll? n. Is positive identification required of each person receiving pay? o. Do you have employees acting in the capacity of an in house claims adjuster? Purchasing and Inventory p. Are all persons engaged in purchasing prohibited from taking part in receiving the inventory? q. Are all shipping and receiving activities reconciled to all applicable sale or purchase orders? r. Does any employee have access to the purchasing system and also the accounts payable system? s. Do you have a system to detect payment to fictitious suppliers? t. Do you verify tax ID numbers for all vendors? u. Is a complete inventory made with physical check of stock and equipment? 5. Funds Transfer Procedures Yes No a. What departments conduct wire transfers? b. Do you maintain a fully documented procedure manual covering all wire transfer procedures? c. Are all payment instructions executed under a sequential numbering system? d. Is there an internal audit department which includes E.D.P. auditing? e. If there is no internal audit department, please advise how this function is fulfilled: This function is handled by the Auditor General s office. f. If you utilize consultants, do you change passwords when they finish their work? g. What is the total annual volume of funds transferred? $0.00 h. What is the largest amount one person can transfer? $0.00 i. What is the average size of transfers? $0.00 2

14 j. Are all funds transfer functions handled by banks and/or institutions? k. Do you have facilities to transfer funds yourself without involving third parties? 5. Funds Transfer Procedures (continued) l. Are all telephone transfer instructions given to banks confirmed in writing within 24 hours? Not Applicable m. Is there segregation of duties so that no one employee can initiate and complete transactions without approval by others? n. Do you change passwords when employees leave? o. Describe controls in place to prevent unauthorized use of computers by employees or others (i.e. are computer rooms locked, maintenance ports protected, etc.)? Each employee logs off each night & IT Section. p. What is the total number of employees who have the authority to make transfers? None q. Do you utilize port security that detects unusual activity? Not Applicable r. How do you detect whether an employee has exceeded their authority? Not Applicable 6. Vendor Information Yes No a. Are background checks performed on vendors in order to determine ownership and financial capability prior to doing business with them? b. Is an authorized vendor list utilized and updated for all annual purchases, with competitive bidding required over stated amounts? c. Are requisitions and purchase orders issued only after the approval of specified personnel within specified limits? d. Is each cash disbursement based on a recognized liability, accurately prepared, and appropriately authorized, including comparisons to authorized vendor lists and receiving reports? e. Are perpetual inventories maintained of materials and supplies and periodically verified by physical count? f. Are vendors provided with a statement of your conflict of interest and gift policy (prohibiting gifts of any significant value)? g. Are vendors asked to disclose any gifts or favors offered or requested or other questionable behavior by employees? h. Do the same controls apply to locations outside of the United States? Not Applicable 7. Prior Insurance Yes No a. Has any similar insurance been declined or canceled during the past three years? If yes, please explain b. Prior insurance to be superseded Check here if none Form of Insurance Effective Date Expiration Date Government Crime State of Florida 01/01/ /01/2015 Limit of Insurance Refer to Policy # CCP Name of Insurance Company Fidelity & Deposit Company 8. Loss History Enter all claims or occurrences whether or not paid that may give rise to claims for the prior 5 years. Check here if none Date of Occurrence Type/Description of Occurrence or Claim Date of Claim Amount Paid Claim Status Open Closed 3

15 8. Loss History (continued) Comments/Corrective Action Taken: Not Applicable 9. Classification of Employees and Locations Grand total of ALL employees: 408 # of CLASS PLEASE ATTACH TOTAL EMPLOYEE CENSUS BY DEPARTMENT Note: Persons required by law to be individually bonded and treasurers or tax collectors by whatever titles know are automatically excluded. If insurance is desired on any of your appointed or elected agents please complete the following: Capacity in Which Each Agent Serves 10. Money - Securities Which locations require Money and Securities Coverage? $ $ $ $ Limit of Insurance Type Inside Messenger #1 Messenger #2 Money Securities (other than Payroll Checks) Checks (Excluding Retail Checks) Payroll Checks Money Overnight Securities (In Bank/Safe Deposit) Please advise if you need to temporarily increase the above limits for what departments and for what timeframe. 11. Premises/Safe Protection a. What type of alarm(s) do you have at each of your premises? Hold-up Alarm Premises Alarm Safe Alarm Local Gong Central Station Alarm Police Connected Alarm If alarms vary from location to location, please explain: Honeywell EBI multi-line points connected to operations control central at DMS. b. Please specify the number of guards and/or watchpersons on duty each shift: 2 c. Please describe any additional protection (e.g. fences, floodlights, etc.): 12. Internet Security Yes No a. Do you buy or sell goods via the internet? b. Do you have a firewall? c. Do you have an intrusion detection system that identifies unauthorized access? If an intrusion is suspected, review firewall logs to determine the issue. d. Do you have documented internet guidelines for employees? e. Do you have documented emergency procedures? f. Has your computer system ever been invaded by a hacker or virus? 4

16 If yes, when and what controls have been implemented to prevent further incidences? SQL injection on web page-application code was modified to prevent further attacks. Implemented code reviews to avoid similar issues with other applications. Ongoing in 2014 Viruses arriving via Implementing IronPort spam filtering to resolve this. 13. Food Stamp Procedures Yes No Please complete this section if your organization handles Food Stamps, Vouchers or Debit Cards Not Applicable a. Where is the bulk supply of food stamp coupons or debit cards stored? Who has access to this storage area? 13. Food Stamp Procedures (continued) Not Applicable b. How often are they inventoried? Who has the ability to secure the coupons? c. Are those employees specifically responsible for issuance restricted from access to storage and issuance areas? d. How do you distribute food stamps or debit cards to recipients? e. How are coupons secured for transit? Are they stored in a locked container? Who is responsible for transit? f. When are they activated and by whom? g. If a card is reported lost or stolen, how are they replaced? What controls are in place to prevent duplicates from being issued? h. Safe/Vault Manufacturer Label Door Type Combination Locks Thickness UL/SNMA Class Round Square Outer Inner Chest Door Wall NOTICE TO 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. Applicant Signature: Title: Date: Please submit the Crime ITB Excel workbook with along with this application. 5

17 Department of Transportation (DOT) Location Detail Limits Inside, Per Location Limits Outside, Per Location Location Department Cash Checks Cash Checks collection Number of sites per Locations location Description Address DOT $ 9, Toll Facility SR 834 / Sample Road, MP 69 Coral Springs FL DOT $ 6, Toll Facility Coconut Creek / Pompano Beach, MP 67 Pompano Bch. FL DOT $ 5, SunPass Cen7941 Glades Road Boca Raton Boca SunPass FL DOT $ 5, SunPass CenSnapper Creek service plaza Snapper Creek SunPass Service center FL DOT $ 8, Toll Facility Atlantic Ave, MP 81 Delray Beach FL DOT $ 8, Toll Facility Boca Raton, MP 75 Boca Raton FL DOT $ 12, Toll Facility Sunrise Blvd., MP 58 Sunrise FL DOT $ 11, Toll Facility Suncoast Parkway, Exit 53 Oak Hammock FL DOT $ 9, Toll Facility Griffin Rd, MP 53 Ft. Lauderdale FL DOT $ 9, Toll Facility Boyton Beach, MP 86 Boyton Beach FL DOT $ 14, Toll Facility Polk Parkway East, Exit 21 Polk Parkway East FL DOT $ 15, Toll Facility SR714 & Turnpike MP 109 Palm Beach Gardens FL DOT $ 20, Toll Facility SR 80 / US 98 / Sotheren Blvd, MP 97 West Palm Beach FL DOT $ 18, Toll Facility Okeechobee & Turnpike Entrance West Palm Beach FL DOT $ 20, Toll Facility 6610 Suncoast Parkway Anclote FL DOT $ 19, Toll Facility Suncoast Parkway, Exit 41 Springhill FL DOT $ 20, Toll Facility SR802/Turnpike, Lake Worth entrance Lake Worth FL DOT $ 20, Toll Facility Port St. Lucie Blvd, MP 142 Port St. Lucie FL DOT $ 15, Toll Facility SR 820 / Hollywood, MP 49 Hollywood FL DOT $ 14, Toll Facility Dolphin Center, MP 2 Miami FL DOT $ 20, Toll Facility Martin Hwy/SR714, MP 133 Stuart FL DOT $ 13, Toll Facility Commercial Blvd./ Fort Lauderdale North, MP 62 Tamarac FL DOT $ 25, Toll Facility SR 50 / Clermont, MP 273 Clermont FL DOT $ 21, Toll Facility Polk Parkway Central, Exit 13 Polk Parkway Central FL DOT $ 25, Toll Facility US 192, MP 1 Celebration FL DOT $ 20, Toll Facility Pinellas Bayway Pinellas Bayway FL DOT $ 82, Toll Facility Garcon Point Bridge Santa Rosa FL DOT $ 31, Toll Facility 1500 E. Polk Parkway Polk Parkway West FL DOT $ 46, Toll Facility th Street South Skyway Bridge North FL DOT $ 46, Toll Facility S/End of Bridge, Terra Ceia Skyway Bridge South FL DOT $ 30, Toll Facility Veteran's Expressway Sugarwood FL DOT $ 30, Toll Facility SR 500 / Orange Blossom Trail, MP 254 Orlando FL DOT $ 30, Toll Facility Western Beltway Mainline, MP 6 Orlando FL DOT $ Toll Facility W. Sunrise Blvd. Sawgrass Sunrise FL DOT $ Toll Facility 3401 Sawgrass Espressway Sawgrass Deerfield FL DOT $ 35, Toll Facility I-4 MP 259 Orlando FL DOT $ 40, Toll Facility SR528, Exit on Turnpike MP255 Bee Line West FL DOT $ 40, Toll Facility E. Irlo Bronson Hwy, MP244 Kissimmee FL DOT $ 45, Toll Facility Indiantown Rd & Turnpike MP 116 Jupiter FL DOT $ 30, Toll Facility MP193 Florida Turnpike on SR 60 YeeHaw Junction FL DOT $ 41, Toll Facility 9110 Veteran's Expressway Anderson FL DOT $ Toll Facility NW Sunshine Parkway Golden Glades FL DOT $ 40, Toll Facility Osceola Parkway, MP 249 Osceola FL DOT $ 33, Toll Facility Cypress Creek Rd/Turnpike, MP63 Cypress Creek FL DOT $ 65, Toll Facility SR70/Kings Highway & Turnpike Entrance Ft Pierce FL DOT $ 30, Toll Facility I-75 & US27 Everglades Pkwy East FL DOT $ 30, Toll Facility Everglades Parkway West Everglades Pkwy West FL DOT $ 90, Toll Facility 875 Oakway Street, Exit 48 Seminole I FL DOT $ 100, Toll Facility SR91/Turnpike, MP88 Lantana FL DOT $ 120, Toll Facility 6600 Blue Cedar Rd., MP288 Leesburg FL DOT $ 69, Toll Facility 1200 White Pt. Rd. Midbay Bridge FL DOT $ 160, Toll Facility 3405 Friars Cove Road/Turnpike, Mp236 Three Lakes FL 52

18 Department of Veteran s Affairs (DVA) Location Detail Limits Inside, Per Location Limits Outside, Per Location Location Department Cash Checks Cash Checks Number of Locations Description Address DVA $ - $ 10,000 $ - $ - 2 Admin Offices Ulmerton Road, Largo/400 South Monroe St., Suite 2105 Tallahassee Largo/Tallahassee FL 33778/32399 DVA $ 4,500 $ 50,000 $ - $ - 1 Domiciliary Home 751 SE Sycamore Terrace Lake City FL DVA $ 1,000 $ 50,000 $ - $ - 1 Nursing Home 1920 Mason Ave. Daytona Bch. FL DVA $ 1,000 $ 50,000 $ - $ - 1 Nursing Home 6919 Parkway Blvd. Land O' Lakes FL DVA $ 1,000 $ 50,000 $ - $ - 1 Nursing Home 8401 W. Cypress Drive Pembroke Pines FL DVA $ 1,000 $ 50,000 $ - $ - 1 Nursing Home 4419 Tram Rd Terrace Panama City FL DVA $ 1,000 $ 50,000 $ - $ - 1 Nursing Home Grayton Terrace Port Charlotte FL DVA $ 1,000 $ 50,000 $ - $ - 1 Nursing Home 4650 State Road 16 St. Augustine FL

19 Agency or University making application: Department of Veterans Affairs Principal address: Ulmerton Road #K, Largo, FL City: Largo State: FL Zip: Any excluded entities: Policy Effective Period 1/1/2015, 12:01 am To 1/1/2016, 12:01 am 1. Insuring Agreement Limit of Insurance Deductible 1. Employee Dishonesty $500,000/$500,000 $10, Forgery or Alteration 3. Inside Premises $500,000/$500,000 $10, Outside Premises $500,000/$500,000 $10, Computer Fraud Not covered 6. Money Orders and Counterfeit Paper Currency Not covered 7. Funds Transfer Fraud Not covered 8. Faithful Performance Coverage Yes No If Faithful Performance of Duty is requested, please cite statutory provision or indicate None None 2. Coverage Amendments (Endorsements) Yes No a. Is Kidnap, Ransom, and Extortion coverage desired? (separate application required) b. Description of your organization: State Agency Other c. Is Insurance being provided for a State college or university? d. Description of operations for covered entities: State Veterans Nursing Homes, State Veterans Domiciliary, Administration offices e. Do you receive payments via the internet? (If yes, please compete the Internet Security Section 12 of this application) 3. Audit Procedures Yes No a. Is there an annual audit complete by a: State Agency Public Accountant If yes, how frequently? Quarterly Semiannually Annually - 2 years b. Does the state auditor conduct an audit annually or on a surprise basis? Surprise c. Are all departments and agencies audited? d. Does the auditor have the authority to check any record at any time? e. If weaknesses are discovered, to whom does the auditor report to for corrections? Agency Head f. Date of completion of last audit: State 8/9/2013 State of FL-Auditor General g. Do you audit your wire funds transfer procedures? N/A h. Do you audit the usage of grant funds? i. Please list your divisions/locations that accept cash payments (Ex: DMV, licensing and permit agencies, toll collections, etc.) Division / Locations Computerized Audited Annually #04116 Jenkins Veterans State Domiciliary/Lake City Yes No Yes No #03685 Bennett Veterans State Nursing Home/Daytona Bch Yes No Yes No 1

20 #05007 Lopez State Veterans Nursing Home/Land O Lakes #05121 Nininger State Veterans Nursing Home/Pembroke Pines #04270 Sims State Veterans Nursing Home/Panama City #04277 Jacobson State Veterans Nursing Home/Pt Charlotte #04823 Lassen State Veterans Nursing Home/St Augustine **Audit monthly the cash that is deposited or collected from our residents. Additional locations are provided on the Crime Schedule attached hereto. Yes No Yes No 4. Internal Controls Yes No Bank Accounts a. Are bank accounts reconciled monthly? b. Are bank accounts reconciled by someone not authorized to deposit, withdraw, or write checks? Checks and Securities c. Is countersignature of all checks required? YES Above what amount? ALL d. Do all vouchers or other supporting records accompany all checks to be signed? e. Are vouchers/supporting records stamped PAID when checks are signed? f. Are controls set up to prevent unauthorized use of check signing machines and/or signature stamps? g. Are your systems designed so that no single employee can control a transaction from beginning to end (e.g. approve a voucher, request and sign a check?) h. Are securities subject to the joint control of two or more employees? i. Is a positive pay system used? Payroll j. Do you screen your employees for prior acts of dishonesty? If not, which departments employ those without background checks? k. Do you use drug free workplace programs? l. Is the payroll made up by persons other than those who distribute it to employees? m. Are all persons who are authorized to hire and/or fire employees prohibited from distributing the payroll? n. Is positive identification required of each person receiving pay? o. Do you have employees acting in the capacity of an in house claims adjuster? Purchasing and Inventory p. Are all persons engaged in purchasing prohibited from taking part in receiving the inventory? q. Are all shipping and receiving activities reconciled to all applicable sale or purchase orders? r. Does any employee have access to the purchasing system and also the accounts payable system? s. Do you have a system to detect payment to fictitious suppliers? t. Do you verify tax ID numbers for all vendors? u. Is a complete inventory made with physical check of stock and equipment? 5. Funds Transfer Procedures Yes No a. What departments conduct wire transfers? N/A Do not conduct wire transfers b. Do you maintain a fully documented procedure manual covering all wire transfer procedures? N/A c. Are all payment instructions executed under a sequential numbering system? N/A d. Is there an internal audit department which includes E.D.P. auditing? N/A 2

21 e. If there is no internal audit department, please advise how this function is fulfilled: f. If you utilize consultants, do you change passwords when they finish their work? N/A g. What is the total annual volume of funds transferred? None N/A h. What is the largest amount one person can transfer? N/A i. What is the average size of transfers? N/A j. Are all funds transfer functions handled by banks and/or institutions? N/A k. Do you have facilities to transfer funds yourself without involving third parties? N/A 5. Funds Transfer Procedures (continued) l. Are all telephone transfer instructions given to banks confirmed in writing within 24 hours? N/A m. Is there segregation of duties so that no one employee can initiate and complete transactions without approval by others? N/A n. Do you change passwords when employees leave? N/A o. Describe controls in place to prevent unauthorized use of computers by employees or others (i.e. are computer rooms locked, maintenance ports protected, etc.)? N/A p. What is the total number of employees who have the authority to make transfers? N/A q. Do you utilize port security that detects unusual activity? N/A r. How do you detect whether an employee has exceeded their authority? N/A 6. Vendor Information Yes No a. Are background checks performed on vendors in order to determine ownership and financial capability prior to doing business with them? b. Is an authorized vendor list utilized and updated for all annual purchases, with competitive bidding required over stated amounts? c. Are requisitions and purchase orders issued only after the approval of specified personnel within specified limits? d. Is each cash disbursement based on a recognized liability, accurately prepared, and appropriately authorized, including comparisons to authorized vendor lists and receiving reports? e. Are perpetual inventories maintained of materials and supplies and periodically verified by physical count? f. Are vendors provided with a statement of your conflict of interest and gift policy (prohibiting gifts of any significant value)? g. Are vendors asked to disclose any gifts or favors offered or requested or other questionable behavior by employees? h. Do the same controls apply to locations outside of the United States? N/A 7. Prior Insurance Yes No a. Has any similar insurance been declined or canceled during the past three years? If yes, please explain b. Prior insurance to be superseded Check here if none Form of Insurance Effective Date Expiration Date Government Crime State of Florida 01/01/ /01/2015 Limit of Insurance Refer to Policy # CCP Name of Insurance Company Fidelity & Deposit Company 8. Loss History Enter all claims or occurrences whether or not paid that may give rise to claims for the prior 5 years. Check here if none 3

22 Date of Occurrence State of Florida Type/Description of Occurrence or Claim Date of Claim Amount Paid Claim Status Open Closed 8. Loss History (continued) Comments/Corrective Action Taken: 9. Classification of Employees and Locations Grand total of ALL employees: (includes 162 OPS) # of CLASS PLEASE ATTACH TOTAL EMPLOYEE CENSUS BY DEPARTMENT Note: Persons required by law to be individually bonded and treasurers or tax collectors by whatever titles know are automatically excluded. If insurance is desired on any of your appointed or elected agents please complete the following: Capacity in Which Each Agent Serves 10. Money - Securities $ $ $ $ Limit of Insurance Which locations require Money and Securities Coverage? #04116 Jenkins Veterans State Domiciliary, 751 Sycamore Terr, Lake City, FL #03685 Bennett Veterans State Nursing Home, 1920 Mason Ave, Daytona Bch, FL #05007 Lopez State Veterans Nursing Home, 6919 Parkway Blvd, Land O Lakes FL #05121 Nininger State Veterans Nursing Home, 8401 W Cypress, Pembroke Pines, FL #04270 Sims State Veterans Nursing Home, 4419 Tram Rd., Panama City, FL #04277 Jacobson State Veterans Nursing Home, Pt Charlotte, FL #04823 Lassen State Veterans Nursing Home, St Augustine, FL #03032 FDVA Administration Office, (Mary Grizzle Bldg) Ulmerton Rd. #K, Largo, FL Type Inside Messenger #1 Messenger #2 Money Securities (other than Payroll Checks) Checks (Excluding Retail Checks) Payroll Checks Money Overnight Securities (In Bank/Safe Deposit) Please advise if you need to temporarily increase the above limits for what departments and for what timeframe. 11. Premises/Safe Protection 4

23 a. What type of alarm(s) do you have at each of your premises? Hold-up Alarm Premises Alarm Safe Alarm Local Gong Central Station Alarm Police Connected Alarm If alarms vary from location to location, please explain: b. Please specify the number of guards and/or watchpersons on duty each shift: c. Please describe any additional protection (e.g. fences, floodlights, etc.): floodlights 12. Internet Security Yes No a. Do you buy or sell goods via the internet? b. Do you have a firewall? c. Do you have an intrusion detection system that identifies unauthorized access? d. Do you have documented internet guidelines for employees? e. Do you have documented emergency procedures? f. Has your computer system ever been invaded by a hacker or virus? If yes, when and what controls have been implemented to prevent further incidences? 13. Food Stamp Procedures YES No Please complete this section if your organization handles Food Stamps, Vouchers or Debit Cards a. Where is the bulk supply of food stamp coupons or debit cards stored? Who has access to this storage area? 13. Food Stamp Procedures (continued) b. How often are they inventoried? Who has the ability to secure the coupons? c. Are those employees specifically responsible for issuance restricted from access to storage and issuance areas? d. How do you distribute food stamps or debit cards to recipients? e. How are coupons secured for transit? Are they stored in a locked container? Who is responsible for transit? f. When are they activated and by whom? g. If a card is reported lost or stolen, how are they replaced? What controls are in place to prevent duplicates from being issued? h. Safe/Vault Manufacturer N/A Label Door Type Combination Locks Thickness UL/SNMA Class Round Square Outer Inner Chest Door Wall NOTICE TO 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. Applicant Signature: Title: Date: Please submit the Crime ITB Excel workbook with along with this application. 5

24 Florida Agriculture and Mechanical University (FAMU) Location Detail Limits Inside, Per Location Limits Outside, Per Location Location Number of Department Cash Checks Cash Checks Description Address Locations FAMU $ 75,000 $ 900,000 $ 75,000 $ 900,000 1 University Main Campus-Wahnish Way Tallahassee FL 1