FIDELITY BOND CERTIFICATION FORM

FIDELITY BOND CERTIFICATION FORM


LOUISIANA DEPARTMENT OF LABOR CAREER SOLUTIONS CENTER

NAME__________________________________________________

ADDRESS________________________________________________

CITY/STATE/ZIP__________________________________________

EMPLOYER RECEIVING BOND:

DATE AFFIRMED______/_______/____

COMPANY/AGENCY NAME___________________________________________________

CONTACT PERSON NAME___________________________________________________

FEDERAL ID #_____________________________________________

ADDRESS_________________________________________________

CITY/STATE/ZIP___________________________________________

WORKER COVERED BY BOND

LAST NAME___________________________

FIRST NAME__________________________

BOND EFFECTIVE DATE _____/_____/_____

SOC. SECURITY #_____________________

BOND INSURANCE AMOUNT: TOTAL AMOUNT

NEW_____ $ ,000

RENEWAL AMOUNT $_____ _________________________
($5, 10, 15, 20 OR $25K)

OFFICIAL INSURANCE BOND STAMP(S)*





________________________________________________________
*One stamp for each $5000 of bond insurance issued; maximum is $25,000 & requires 5 stamps.
Approved:


___________________________________________________
Paula Collins , Workforce Development Supervisor II


MAIL TO: LOUISIANA DEPARTMENT OF LABOR
ATTENTION: PAULA COLLINS
P.O. BOX 94094 - 3RD FLOOR ANNEX
BATON ROUGE, LA 70804-9094
PHONE (225) 342-4901 FAX (225) 342-3282

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OPERATIONAL DEFINITIONS

MAIL TO: The completed FIDELITY BOND CERTIFICATION FORM is to be mailed to the Louisiana Department of Labor Administrative Office, Attention: Paula Collins where it will be processed for the mailing of a Fidelity Bond to the employer who hired the bondee. The McLaughlin Company serves as agent for Travelers Casualty and Surety Company of America in the issuance of this bond.

LOUISIANA DEPARTMENT OF LABOR: This is the organization that purchased a fidelity bond package from The McLaughlin Company. The bonds are to be issued to employers, free-of-charge, as an incentive for the hiring of ex-offenders and other at-risk job applicants. These job hires must earn wages subject to automatic paycheck deductions for Federal taxes.

EMPLOYER RECEIVING BOND: DATE AFFIRMED: This is the date that the employer agreed (verbally) to hire a job applicant referred by a Louisiana Department of Labor Career Solutions Center on condition that a Fidelity Bond would be issued to the employer. This date cannot be later than the applicant’s first day of work (see BOND EFFECTIVE DATE BELOW), but can be the same day that the applicant is scheduled to start work.

WORKER COVERED BY BOND: This is any individual who has a record of arrest, conviction or imprisonment (including anyone who has ever been on probation and/or released from jail or prison) or is otherwise considered “at-risk” due to any of the following circumstances: is in substance abuse recovery (history of alcohol or drug abuse); welfare recipient and others having poor financial credit history and/or ever declared personal bankruptcy; was discharged dishonorably from the military; is “economically disadvantaged “ and lacks a work history; or for other reasons lacks personal credibility that is a barrier to employment which can be removed by issuance of a Fidelity Bond.

BOND EFFECTIVE DATE: This is the date scheduled by the employer as the first day of work for the job applicant. The bond insurance begins on that date and remains in effect for a six-month duration.

BOND INSURANCE AMOUNT: This is the dollar amount of insurance provided by the Fidelity Bond to protect the employer against any employee dishonesty. The TOTAL AMOUNT identified can be either 5, 10, 15, 20 or 25K (no other amounts are acceptable; $5K is the minimum bond amount; $25K is the maximum). It should be noted that the bond issued has no deductible amount; therefore, the employer receives coverage for the full bond insurance amount.

NEW or RENEWAL: This space is to designate with a “check mark” whether the bond issued is NEW (i.e., first time a bond is being issued to the employer to cover the specific worker) or is a RENEWAL
(i.e., a second six-months of free insurance is being issued to the employer covering the same worker).

OFFICIAL BOND INSURANCE STAMP(S): The Louisiana Department of Labor. Purchaser of a Fidelity Bond package from The McLaughlin Company has been provided a set of stamps, one or more of which will be affixed to each FIDELITY BOND CERTIFICATION FORM, whether new or renewal. The number of stamps provided was based upon the package size purchased (e.g., 25 stamps are provided for a 25 bond package), and each stamp represents one unit of bonding/$5,000 insurance coverage for a six-month duration.

These stamps are numbered sequentially so that The McLaughlin Company can automatically know which bond package purchaser has issued a bond. For each $5,000 of insurance specified for BOND INSURANCE AMOUNT (see above), one stamp is to be affixed in space at the bottom of the CERTIFICATION FORM (e.g., to issue a $10,000 bond to the employer, two stamps are to be affixed to the FORM).

SIGNATURE: The Form is signed by the designated staff person assigned by the Louisiana Workforce Commission.