Application for Bond - Any Kind - Public Official Bonds Tampa, Fl

Application for Bond - Any Kind

CNA Surety

www.cnasurety.com

Form 10

Application for Bond - Any Kind

The submission of this application by the Applicant and its owners is authorization to the Company to obtain a credit report on the Applicant and its owners. The Company reserves all rights and legal duties associated with this application and any and all bonds issued as a result; including, but not limited to the right to handle or settle any claim or suit in good faith and the Company's decision shall be binding on the Applicant and its owners. This Agreement shall be in addition to and not in lieu of or in replacement of all other indemnity agreements.

Checkboxes

Applicant Name (Exactly as shown on License or Bond) Please print or type

Social Security #

Date

Marital Status

Married

Single

Residence Address

City

State/Province

Zip/Postal

Personal Phone

Personal Fax

Personal Email

Business Address

City

State/Province

Zip/Postal

Business Phone

Business Fax

Business Email

Occupation or Business

How long so engaged?

Previous Surety

Yes

No

If yes, give name and reason for change

Type of Bond

Amount of Bond

Effective Date

Complete Name and Address of Obligee

Financial Statement

Check applicable section to see whether a financial statement is necessary.

FINANCIAL STATEMENT as of

Check One:

Business Financial Statement

Personal Financial Statement

Assets

Cash (List Banks)

Stocks & Bonds (Describe)

Notes Receivable (Describe)

Merchandise or Material in Stock

Accounts Receivable

Real Estate (Homestead)

Real Estate (Investment)

Furniture & Fixtures

Other Assets (Describe)

Total Assets

Liabilities

Accounts Payable

Taxes Due & Accrued

Notes Payable to Bank

Notes Payable to Others (Describe)

Mortgage on Real Estate (A)

Mortgage on Real Estate (B)

Other Liabilities (Describe)

TOTAL LIABILITIES

Capital Stock (Paid In)

NET WORTH OR SURPLUS

Total Liabilities and Net Worth

Gross Sales (2 years ago)

Gross Sales (Last Year)

Net Income (2 years ago)

Net Income (Last Year)

Indemnity

The undersigned applicant and indemnitors hereby request Western Surety Company, Universal Surety of America, Surety Bonding Company of America and any affiliated company, their successors or assigns (with such company/companies referred to herein as the "Company") to become their surety. The undersigned applicant and indemnitors hereby represent and warrant: (a) they have a substantial, material, and/or beneficial interest in obtaining bonds; (b) all information provided to the Company is true, accurate and complete; and (c) they hold the title shown with their signature and that they are authorized by the business entity to execute this document. The undersigned applicant and indemnitors authorize the Company to verify this information at the time of application and as needed, on an ongoing basis and to obtain additional information from any source, including obtaining credit reports at the time of application, in any review or renewal, at the time of any potential or actual claim, or for any other legitimate purposes as determined by the Company in its reasonable discretion, and jointly and severally agree:

(1) To pay premiums, including renewal premiums and any other charges, to the Company or its agents, when due.
(2) To completely INDEMNIFY the Company from and against any liability, loss, cost, attorneys' fees and expenses whatsoever which the Company shall at any time sustain as surety or by reason of having been surety on this bond or any other bond issued for any applicant and or indemnitor, or for the enforcement of this agreement, or in obtaining a release or evidence of termination under such bonds, regardless of whether such liability, loss, costs, damages, attorneys' fees and expenses are caused, or alleged to be caused, by the negligence of the Company.
(3) To furnish the Company with satisfactory and conclusive termination evidence that there is no further liability on this bond or any other bond issued for applicant.
(4) Upon demand by the Company for any reason whatsoever, to deposit current funds with the Company in an amount sufficient to satisfy any claim against the Company by reason of such suretyship.
(5) That the Company shall have the right to handle or settle any claim or suit in good faith and the Company's decision shall be binding and conclusive on the undersigned. An itemized statement of loss and expense incurred by the Company, shall be prima facie evidence of the fact and extent of the liability of the undersigned to the Company.
(6) That the Company may decline to become surety on any bond and may cancel or amend any bond without cause and without any liability which might arise therefrom.
(7) That the Company shall, without notice, have the right to alter the penalty, terms and conditions of any bond issued for undersigned, and this agreement shall apply to any such altered bond. The liability for the undersigned shall not be affected by the failure of the undersigned to sign any bond, nor any claim that other indemnity or security was obtained, nor by the release of any indemnity, nor the return or exchange of any collateral obtained and if any party signing this agreement is not bound for any reason, this agreement will still be binding on each and every other party.
(8) That if a contract or performance bond is issued hereunder, the undersigned hereby assign to the Company any monies now due or hereafter becoming due under the contract, including all deferred payments and retained percentage, supplies, tools, plants, equipment and materials due or used on the contract.
(9) At the Company's discretion, this indemnity agreement shall be governed in all respects by the laws of the State of South Dakota and the undersigned applicant and indemnitors consent to the jurisdiction of the courts of the State of South Dakota and the United States District Court for the District of South Dakota in all actions or proceedings arising from or relating to this indemnity agreement.
(10) That this indemnity may be terminated by the undersigned, or any one or more parties so designated, upon written notice sent registered mail to the office of the Company at Sioux Falls, South Dakota 57103, of not less than twenty (20) days. In no event, shall any termination notice operate to modify, bar, discharge, limit, affect or impair the liability of any party hereto, for any bonds, undertakings and obligations executed prior to the date of the Company's receipt and notice of such termination.
(11) In the event of any payment by the Company, to pay the Company interest on such amounts at the highest legal rate from the date such payments are made.

Agency

Address

City

State/Province

Zip/Postal

Agent's Code

Signed This Day of:

Signature & Business/Corporate Title

"Indemnitor"

Notes: Personal indemnitors should print and sign their names before the word "indemnitor" in their own handwriting, (e.g. - John Doe John Doe "Indemnitor")

Agent's Recommendation

Tell us what you know and think of the applicant.

Agent: (Check if Applicable)

This correspondence was previously faxed or emailed to CNA Surety.

Important Notice

Please discuss with the applicant the potential use of personal credit history to facilitate the underwiriting review process.

Internal Control Data

Complete for all fidelity submissions or public official over $150,000.

Will applicant sign checks?

Yes

No

Is countersignature required?

Yes

No

By Whom?By Whom?

Regular Audits?

Yes

No

By Whom?By Whom?

Are bank accounts reconciled by someone not authorized to deposit or withdraw from the accounts?

Yes

No

Applicants Net Worth

Ever Discharged from any Employment?

Yes

No

Why?Why?

1. Public Official Bond

NO FINANCIAL STATEMENT NECESSARY, APPLICANT SIGN APPLICATION OVER $100,000, INTERNAL CONTROL DATA SECTION OVER $150,000

Net Worth: ($)

Elected

Appointed

Date

Term of Office:

Premium will be paid:

Annually?

For Term?

2. Fidelity Bond

NO FINANCIAL STATEMENT NECESSARY. COMPLETE INTERNAL CONTROL DATA.

Title of Position

Main Sources of Organization's Funding

Purpose or Function of Organization

3. Probate Bond

NO FINANCIAL STATEMENT NECESSARY. HAVE APPLICANT SIGN THIS APPLICATION.

Name of Deceased (Ward)

Date

Date of Appointment (If over 6 months, please explain delay.)

Is applicant indebted to the estate or trust?

Yes

No

If Yes, ExplainIf Yes, Explain

Has applicant had prior possession of estate assets (i.e. Power of Attorney, Bank Accounts, etc.)?

Yes

No

If Yes, Explian:If Yes, Explian:

Name and address of attorney (If none, do not write the bond; submit it to our underwriters.)

Phone

Will the attorney remain involved throughout the duration of this estate?

Yes

No

Assets of Estate or Trust (Describe)

Name, Age, and Health status of

minor(s)

incompetent

Applicants relationship to

deceased

ward(s)

Applicant's net worth ($)

Are guardianship funds to be used for support of ward?

Yes

No

Approximately how much per month? (Provide Copy of Court Order Authorizing Monthly Expenditures.)Approximately how much per month? (Provide Copy of Court Order Authorizing Monthly Expenditures.)

What is the source of the guardianship funds? (If an insurance settlement, do not execute the bond; instead refer it to an underwriter.)

Who are the heirs of this estate?

Has anyone objected to the applicant's appointment as fiduciary?

Yes

No

Will any going business of the estate be continued or operated by fiduciary? (If yes, send a copy of court order.)

Yes

No

Is this bond required on the demand of an interested person?

Yes

No

Who?Who?

Name of Court

Address of Court

City

State/Province

Zip/Postal

What is the applicant's experience in handling fiduciary responsibilities?

4.

Referee's

Receiver's

Trustees Bond

NO FINANCIAL STATEMENT NECESSARY. HAVE APPLICANT SIGN THIS APPLICATION.

Plaintiff

Name of Applicant's Attorney

Address of Applicant's Attorney

City

State/Province

Zip/Postal

Defendant

Name of Court

Address of Court

City

State/Province

Zip/Postal

Applicant's Net Worth ($)

5. Court Bond Other Than 3 and 4

HAVE APPLICANT SIGN THIS APPLICATION.

Name of Court

Name of Defendant

Address of Court

City

State/Province

Zip/Postal

Name of Attorney

Address of Attorney

City

State/Province

Zip/Postal

If an Injunction or Restraining Order bond, does applicant anticipate a foreclosure or collection action against him?

Yes

No

If so, submit for underwriting.If so, submit for underwriting.

Explain purpose of bond (submit copy of relevant documents)

6. LICENSE AND PERMIT BOND

HAVE APPLICANT SIGN THIS APPLICATION.

Net Worth ($)

General liability insurance carried?

Yes

No

(Give Limits)(Give Limits)

State license number assigned to applicant, if applicable:

7. Lost Securities

PLEASE HAVE APPLICANT SIGN THIS APPLICATION.

Serial Number and description (Please submit a copy or sample of the form it was on.)

Date of Instrument

Payable to applicant only?

Yes

No

If not, who is it payable to?If not, who is it payable to?

Are Securities Endorsed?

Yes

No

Describe manner of loss

Has notice of loss been given?

Yes

No

When?When?

To Whom?To Whom?

If registered, in whose name?

If a check, has payment been stopped?

Yes

No

If so, when?If so, when?

If a deed of trust or note, has either been involved in a lawsuit?

Yes

No

Was a judgment obtained?

Yes

No

CERTIFICATE OF TITLE BOND

HAVE APPLICANT SIGN THIS APPLICATION.

Vehicle Make

Vehicle Model

Vehicle Year

Vehicle VIN

Is there a lien or lien holder?

Yes

No

If yes, list and explain.

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

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