License and Performance Bonds

Short Form Application for Bond

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Applicant Information









Owner Information (If Applicant Is A Business)







Description Of Bond











Continuous Until Cancelled

Expiration Date

Indemnity Agreement

(A Facsimile And Or Scanned Copy Of This Agreement Shall Be Treated As An Original For All Purposes)

The Undersigned Applicant And Indemnitors, Hereby Certify That The Information Contained In This Application To Be True And Request The Company To Become Surety For And Furnish The Above Bond And Such Other Bond(S) As May Now Or Hereafter Be Requested On Behalf Of The Named Applicant Including Any Continua- Tion, Substitution, Extension, Or Alteration, Thereof, And Hereby Authorize Banks, Materialmen, Or Others, Including Governmental Entities, To Furnish Any Information Requested Concerning Any Transaction With The Undersigned. Should The Company Execute Said Bond(S), The Undersigned Agree As Follows: (1) To Pay The Usual Premiums, Including Renewal Premiums. (2) To Indemnify The Company And Hold It Harmless Against All Loss, Liability, Costs, Claim Damages, Expense, Including, But Not Limited To, Attorney's Fees, Investigative Costs, Etc. Which May Incur By Reason Of The Company Writing Said Bond(S) Or For The Enforcement Of This Agreement. The Company May Decline To Become Surety On Any Bond Of The Applicant And, In Case It Does Act As Surety, Shall Have The Right To Withdraw Or Cancel Same Whenever It Shall See Fit And Shall Not Be Responsible For Any Loss Or Damage That May Be Sustained By Reason Of Such Action. Nothing Shall Be Construed To Waive Or Abridge Any Rights Or Remedies Which The Company Might Have If This Instrument Were Not Executed.

The Agreement shall be effective this

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ARKANSAS: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."

MAINE: "It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or denial of insurance benefits."

COLORADO: "It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies."

NEW JERSEY: "Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties."

NEW MEXICO: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties."

NEW YORK: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."

DISTRICT OF COLUMBIA: "Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant."

FLORIDA: "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."

OHIO: "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."

HAWAII: "For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both."

PENNSYLVANIA: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties."

KENTUCKY: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime."

RHODE ISLAND: Insurer shall place on the application a warning which indicates the existence of a criminal penalty for failure to disclose a conviction for arson.

LOUISIANA: "Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison."

VIRGINIA: "It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits."

TENNESSEE: "It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits."

WASHINGTON: "It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits."