Fidelity Guarantee Policy Form

Employee’s name in full

Age

1. (a) State / Nature of Occupation

(b) Amount of Guarantee required

2. (a) Annual net renumeration from said appointment

(b) Other (annual) Income and how derived

3. (a) Have you any debts or liabilities apart from domestic ones?

(b) If so give amount and particulars

4. (a) Are you a shareholder?YesNo

(b) If not, do you reside with relatives?

c) Does the furniture belong to you?YesNo

d) If so, state value

5. (a) Are you single, married, or a widower?

(b) State number of persons dependent upon you

6. (a) Are you security for any person?YesNo

(b) If so, State the amount and full particulars

7. Have you any Life Assurance?YesNo

If yes, state (a) Name of Company

(b) Amount ₵

8. (a) Have you ever been charged with fraud or dishonesty

(b) In arrears or in default in your accounts

9. State where you have been employed during the last five years (From, To, Position, Name & Address of Employer, Reason for leaving)

Amount of Guarantee ₵

Premium ₵