License And Permit Surety Bond License And Permit Surety Bond Applicant InformationApplicant Full Name Email Address* Applicant Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation or Business of Applicant Applicant is...Select One..An IndividualA PartnershipA CorporationAn LLCObligee InformationObligee Full Name Obligee Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Bond InformationType of Bond License Number Amount of BondEffective DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Prior Surety Company Asset InformationDo you own Real Estate?Select One...YesNoWhat are the locations of your Real Estate?StreetCityState Number of Years in Business Business Phone NumberHas Applicant, Stockholder, or Indemnitor ever:Been Cancelled by Surety?Select One...YesNoPlease explain why you were cancelled by SuretyHad a Bond Claim?Select One...YesNoPlease explain why you had a bond claimDeclared Bankruptcy?Select One...YesNoPlease explain the circumstances of the bankruptcy declarationPrior/Pending Tax Liens?Select One...YesNoPlease explain the Prior/Pending Tax LiensPrior/Pending Lawsuits?Select One...YesNoPlease explain the Prior/Pending LawsuitsConvicted of a Felony?Select One...YesNoPlease explain the convictionIndemnity AgreementINDEMNITY AGREEMENT: The undersigned Applicant and Indemnitor(s) all hereinafter called the Indemnitor(s) hereby certify that the foregoing declarations made and answers given, are the truth without reservation, and are made for the purpose of inducing the Surety, to become Surety on a certain bond or undertaking applied for and any renewal and increase of the same or of any bond or undertaking of similar nature given in substitution or renewal thereof (all comprehended in the word “bond” or “undertaking” as herein used), and in consideration of the Surety executing said bond or undertaking do undertake and agree as follows: (1) To hereby authorize the Surety to access their credit records and to make such pertinent inquiry as may be necessary from financial institutions, credit reporting services, persons, firms and corporations in order to confirm and verify information referred to or listed herein; (2) To pay to the Surety the agreed premium upon execution of the Bond(s) and annually in advance thereafter; (3) To furnish the Surety with satisfactory and conclusive termination evidence that there is no further liability on the Bond(s); (4) To perform all the conditions of said Bond(s) and will indemnify and save the Surety harmless from all demands, losses, costs, damages and expenses, including attorney’s fees and costs deemed necessary by the Surety, which Surety may sustain or incur by reason of the issuance of such Bond(s), or obtaining a release of or evidence of termination under such Bond(s); (5) To deposit with Surety on demand an amount sufficient to discharge any claim made or that could be made against the Surety on said Bond(s), whether or not any such claim has been asserted. This sum may be used by Surety to pay any such claim or be held by Surety as collateral against loss or cost on said Bond(s); (6) That the Surety shall have the exclusive right to adjust, settle or compromise any claim under such Bond(s); (7) That the voucher or other evidence showing payment made by the Surety by reason of such Bond(s) or any renewal, extension or substitution thereof shall be conclusive and in any event prima facie evidence of such payment and the propriety thereof and of the liability of the Undersigned therefore to the Surety; (8) The Undersigned further agrees to reimburse the Surety for all expenses, attorney fees and costs incurred by the Surety in enforcing any provision of this Agreement: and (9) In the event the Surety procures the execution of the Bonds by other sureties, or executes the Bonds with co-sureties, or reinsures any portion of said Bonds with reinsuring sureties, then all the terms and conditions of this Agreement shall inure to the benefit of such other sureties, co-sureties and reinsuring sureties, as their interests may appear. (10) The Undersigned agree that this document and any and all bonds issued by the Surety will be subject to the terms of the Uniform Electronic Transactions Act (“UETA”), to the extent that the UETA has been adopted by the State legislature in the relevant jurisdiction, and any and all substantially similar federal or state legislation designed to regulate electronic commerce. Reset signature Signature locked. Reset to sign again SIGNATUREApplicant SignatureEnter Applicant Name (Exactly as it is to appear on Bond): Social Security Number or Federal Tax ID Driver's License Signature of Authorized Representative* Reset signature Signature locked. Reset to sign again Title of Authorized Representative Individual Indemnitor #1Social Security Number or Federal Tax ID of Individual Indemnitor #1 Driver's License of Individual Indemnitor #1 Individual Indemnitor #1 Home Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Signature of Individual Indemnitor #1* Reset signature Signature locked. Reset to sign again Individual Indemnitor #2Social Security Number or Federal Tax ID of Individual Indemnitor #2 Driver's License of Individual Indemnitor #2 Individual Indemnitor #2 Home Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Signature of Individual Indemnitor #2 Reset signature Signature locked. Reset to sign again Δ Have Questions? We are here to help! Please feel free to give us a call and speak to one of our professionals to help with your bonding questions. We look forward to the opportunity of earning your business please contact us today! Contact Us Today Call (925) 391-3175 Contact Us Online or Download Forms
