Application for Appearance Bond SENECA INSURANCE COMPANY, Inc.

160 Water Street, 16th Floor

New York, NY 10038-4922

  1. Agency

Agency: ______Agent’s Name: ______

Transfer Bond Rewrite Posting Posting Agent Original POA#: ______Requesting Agent: ______

POA#: ______Bond Amount: $______Posting Date: ______

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  1. Notification – Defendant/Indemnitor/Attorney

DEFEDANT: ______Address: ______Phone: ______

INDEMNITOR:______Address: ______Phone: ______

ATTORNEY: ______Address: ______Phone: ______

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  1. Court

Case#: ______Charges: ______

Charges Continues: ______

Court Date: ______Time: ______AM PM

Court: ______Address: ______

Premium Amount $: ______

Premium Paid In Full Premium Owed Amount: $ ______Paid: $______

Premium billed to: ______

Comments: ______

NOTE: For multiple bonds only these fields need to be filled out on the second application

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  1. Indemnitor

Full Name: ______Home Phone: ______

PLEASE PRINT – First/Middle/Last Name

Current Address: ______

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  1. Personal Description / Marks / Nicknames

Weight: ______Height: ______Race: ______Sex : Male Female

Color of Eyes: ______Color of Hair: ______Date of Birth: ______Nationality: ______

C’tzshp Status: ______Place of Birth: ______Nickname or Alias: ______

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  1. Mortgage/Landlord/Residence Information

How long have you lived at current address? ______Do you Own or Rent your home? Other ______

Mortgage Company or Person from whom you rent: ______

Address of: Mortgage Co. or Landlord______

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  1. Marital Status / Children

MarriedDivorcedSeparatedWidowedSingle Spouse’s Name: ______

Spouse’s Occupation: ______Spouse’s Employer: ______Phone: ______

No. of Children: ______Ages: ______Are you responsible for anyone else’s support? ______

Child’s Name: ______Age: ______School Attended: ______

Child’s Name: ______Age: ______School Attended: ______

Child’s Name: ______Age: ______School Attended: ______

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  1. Employment

Your occupation: ______Company Name: ______Business Phone: ______

Name of Supervisor: ______Address: ______Years Employed with Co: ______

Former Employer(s): ______

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  1. SS# / DL# / Car / Credit Cards

Social Security #: ______Drivers License #: ______State: ______

Describe Car: Year: ______Make: ______Color: ______Model: ______Tag No. ______

Financial Institute: ______Principal Balance: $______

Credit Card Name & Acct #: ______Credit Card Name & Acct #: ______

Credit Card Name & Acct #: ______Credit Card Name & Acct #: ______

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  1. Attorney

Full Name: ______

Address: ______Phone: ______

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  1. Personal References –or Friends

A)Name: ______Occupation: ______Yrs. Known______

Address: ______Phone: ______

B)Name: ______Occupation: ______Yrs. Known______

Address: ______Phone: ______

C)Name: ______Occupation: ______Yrs. Known______

Address: ______Phone: ______

  1. Relatives (If not living, write deceased) COMPLETE FULLY

RELATION NAME OCCUPATION ADDRESS PHONE

Father: ______/______/______/______

Mother: ______/______/______/______

Sister: ______/______/______/______

Sister: ______/______/______/______

Brother: ______/______/______/______

Brother: ______/______/______/______

Father-In-law: ______/______/______/______

Mother-in-law______/______/______/______

Cousin: ______/______/______/______

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  1. Type of Collateral

Cash Cash Value Equity Assignment Note &/or Mortgage Deed Miscellaneous

OWNER(S) NAME: ______

OWNER(S) ADDRESS & PHONE:______

OWNER(S) NAME: ______

OWNER(S) ADDRESS & PHONE:______

OWNER(S) NAME: ______

OWNER(S) ADDRESS & PHONE:______

COLLATERAL DESCRIPTION: ______

______

______

______

______

COLLATERAL LOCATION: ______

______

C.D.# ______Renewal Date: ______Automatic: ______

Social Security #: ______Tax I.D. #: ______

*HOLDS************************************************************************************************************************

Name: ______Phone: ______

Address: ______

Name: ______Phone: ______

Address: ______

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TERMS AND CONDITIONSNOTE: Premium on this Bond is NOT Returnable

The following terms and conditions are an integral part of this application for Appearance bond No. ______dated ______for which ______or its Agent shall receive a premium in the amount of ______($______) Dollars, and the parties agree that said appearance bond is condition upon full compliance of all terms and is a part of said bond and application thereof

  1. ______, as bail, shall have control and jurisdiction over the principal during the term for which the bond is executed and shall have the to apprehend, arrest and surrender the principal to the proper officials at any time as provided by law.
  2. In the event surrender of principal is made prior to the time set for principal’s appearances, and for reason other than as enumerated below in paragraph 3, then principal shall be entitled to a refund of the bond premium.
  3. It is understood and agreed that the happening of any one of the following events shall constitute a breach of principal’s obligations to ______hereunder, and ______shall have the right to forthwith apprehend, arrest, and surrender principal shall have no right to any refund of premium whatsoever. Said events which shall constitute a breach of principal’s obligations hereunder are:

a)If principal shall depart the jurisdiction of the court without the written consent of the court and ______, or its Agent.

b)If principal shall move from one address to another within the State of Florida without notifying ______, or its Agent in writing prior to said move.

c)If principal shall commit any act which shall constitute reasonable evidence of principals’ intention to cause a forfeiture of said bond.

d)If principal is arrested and incarcerated for any offense other than a minor traffic violation.

e)If principal shall make any material false statement in the application or fail to produce agreed collateral.

f)If indemnitor requests principal be surrendered in writing.

Applicant’s Signature: ______Date: ______

SEN-FL135