CONTRACTOR DATA
Swift BondApplication
Fed TaxID
ForSingleBondsor Aggregate Programs upto
$300,000, complete page 1.
ForAggregate Programs inexcess of$300,000, upto$600,000, complete page 1 and page 3.
Date started in Business
Type ofBusiness: / Partnership / (S) Corporation / (C) Corporation / Sole Proprietorship / LLC / LLPCompany Name / Phone
Company Address
Type ofWork
Largest job completed in last 5 years - Contract Price $
CityState
Territory ofOperations
Job Description:
Zip
Are there any unfinished bonded contracts with other sureties, if yes,attach explanation.YesNo
OWNER DATA / INDEMNITORS (Provide the information below on all owners; use additional sheet if necessary)
Name
Name
Address / AddressCity/State/Zip / City/State/Zip
SS# / DOB / SS# / DOB
% ofBusiness Ownership / Married / Yes / No / % ofBusiness Ownership / Married / Yes / No
Spouse Name / Spouse Name
Spouse Employer / Spouse Employer
Spouse Annual Income $ / Spouse Annual Income $
SS# / DOB / SS# / DOB
Credit Reports will be obtained during the underwriting process.
***For newapplicants, complete and sign the General Indemnity Agreement on page 4.***
BOND REQUESTDATA
Ifno bond is needed atthis time,but only prequalification forfuture bonding, check here
Anticipated StartDate
Time forCompletionLiquidated Damages per Day $
Obligee(Who is requiring the contractor get a bond?)
Obligee Address
Job Legal Description
Job Physical Address
Maintenance Period
CityStateZip
*ThisapplicationisnotintendedforuseinconnectionwithSubdivisionorSiteImprovement,AsbestosAbatement,Completion, Hazardous Materials, Multi-Year Contracts, or Service Contracts.
Check andComplete:
(check one only)
(Forprivate jobsor subcontracts, please enclose a copy ofthe contract and bond form forprojects over $150,000.)
BidBond:
ORFinalBond:
Contract Price $
Bid date
Estimated total amount ofbid:$ Bid Bond % or flatamount
Status ofOutstandingBidBonds:
Contract Date (Date when contract is signed)
Performance & Payment BondSupplyBond
SubcontractorPerformance & Payment Bond
StandAloneMaintenance Bond$
Owner:
Awarded?
Yes
Bid secured by:
Check
BondNegotiated
Owner:
Awarded?Yes
Next two lowest bidders
$$
BOND FORMDATA
LibertyQuickAccess FormObligee FormAIAForm
StateFormFederal Contract #
(Send copy forreivew)
AGENCY DATA (To be completed by Agency)
(Send copy forreview)
StateofIncorporation
Agency Name
Agent's Phone #
Liberty Agency Code
IsContractor an existing insurance account?
YesNo
Length ofrelationship
IfContractor is an established Liberty QuickAccess account, provide account #
Page 1 of4
CreditAuthorization
Each Indemnitor authorizes Surety toobtain information from third parties, including personal credit reports, in connection with the Surety's underwriting and each Indemnitor's compliance with indemnity agreements, bonded contracts and bonds. Each Indemnitor releases such third parties from liability resulting from the provision ofsuch information.
FraudNotices:Pleasereviewthestatutoryfraudnoticeapplicabletoyourstate.
Arkansas, Louisiana,Maryland,New Mexico andWest Virginia:Any person who knowingly presents a false or fraudulent claim for payment ofa loss or benefit or knowingly presents false information in an application forinsurance is guilty ofa crime and may be subject tocivil fines and criminal penalties.
Colorado:Itis unlawful toknowingly provide false, incomplete, or misleading factsor information toan insurance company forthe purpose ofdefrauding or attempting todefraud the company. Penalties may include imprisonment, fines, denial ofinsurance, and civil damages. Any insurance company or agent ofan insurance company who knowingly provides false, incomplete, or misleading factsor information toa policyholder or claimant forthe purpose ofdefrauding or attempting todefraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported tothe Colorado Division ofInsurance within the Department of Regulatory Agencies.
District ofColumbia:Any person who knowingly presents a false or fraudulent claim forpayment ofa loss or benefit or knowingly presents false information in an application forinsurance is guilty ofa crime and may be subject tofines and confinement in prison.
Florida:Any person who knowingly and with intent toinjure, defraud, or deceive any insurer files a statement ofclaim or an application containing any false, incomplete, or misleading information is guilty ofa felony ofthe third degree.
Tennessee, Maine,Virginia,andWashington:Itis a crime toknowingly provide false, incomplete or misleading information toan insurance company forthe purpose ofdefrauding the company. Penalties include imprisonment, fines and denial ofinsurance benefits.
Kentucky: Any person who knowingly and with intent todefraud any insurance company or other person files an application forinsurance containing any materially false information or conceals, forthe purpose ofmisleading, information concerning any factmaterial thereto commits a fraudulent insurance act,which is a crime.
New Jersey:Any person who knowingly files a statement ofclaim containing any false or misleading information is subject tocriminal and civil penalties.
New York:Any person who knowingly and with intent todefraud any insurance company or other person files an application for insurance or statement ofclaim containing any materially false information, or conceals forthe purpose ofmisleading, information concerning any factmaterial thereto, commits a fraudulent insurance act,which is a crime, and shall also be subject toa civil penalty not toexceed five thousand dollars and the stated value ofthe claim forsuch violation.
Pennsylvania:Any person who knowingly and with intent todefraud any insurance company or other person files an application for insurance or statement ofclaim containing any materially false information or conceals forthe purpose ofmisleading, information concerning any factmaterial thereto commits a fraudulent insurance act,which is a crime and subjects such person tocriminal and civil penalties.
Oklahoma:WARNING:Any person who knowingly, and with intent toinjure, defraud or deceive any insurer, makes any claim forthe proceeds ofan insurance policy containing any false, incomplete or misleading information is guilty ofa felony.
Ohio:Any person who, with intent todefraud or knowing thathe is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty ofinsurance fraud.
Arizona:For your protection, Arizona law requires the following statement toappear on this form.Any person who knowingly presents a false or fraudulent claim forpayment ofa loss is subject tocriminal and civil penalties.
Contractor's Company Name
Complete thispagefor Aggregate Programs inexcess of$300,000, up to$600,000.
Contractor's Company AddressCityStateZip
FINANCIAL DATA Please submitthe following:
Business FinancialInformationfor (C) Corporations,(S) Corporations, andLLCs:
or
Business FinancialInformationfor SoleProprietorshipsand Partnerships:
and
Provide the company's latest CPA prepared fiscal year-end financial statement.Ifa CPA-prepared financial statement is unavailable, provide the company's in-house prepared fiscal year-end financial statements or Liberty form (S-127) along with the company's mostrecent taxreturn.
Provide the company's latest CPA prepared fiscal year-end financial statement.Ifa CPA-prepared financial statement is unavailable, provide the company's in-house prepared fiscal year-end business financial statement or Liberty form (S-127) and a copy ofSchedule C from the owners' mostrecent personal taxreturns.
Personal FinancialStatements andCertificate ofInsurance
EXPERIENCE DATA
Provide a copy ofeach owner's personal financial statement or Liberty form (S-4597). Include supporting bank and marketable securities statements forverification purposes.
List the three largest contracts completed in the last five years: Owner or GeneralKind ofWork
Location
(City/County, State)
Contract
Price
$
$
$
Year
Completed
Final
GrossProfit
$
$
$
List the two largest jobs you presently have underway, giving the following information: Location
Contract
% of
Estimated
Date tobe
Owner or GeneralKind ofWork
(City/County, State)
Price
$
$
CompletionGrossProfit
$
$
Completed
OPERATIONSDATA
• Type oftrades you perform:
• Trades subcontracted:
GENERAL DATA
Disputes,FinancialDifficulties,Problems,Etc.
Company
Any officer,owner or partner
a. Failed in business or declared bankruptcy? ...... YesNo
YesNo
b. Failed tocomplete a job or been assessed with delay damages?. . . YesNoYesNo c. Been in claim with a Surety or denied bonding?...... Yes No Yes No
d. Been involved in any lawsuits or disputes in the last 5 years? . . . . . YesNoYesNo
e. Do you have any corporate or personal assets
held in trustor escrow accounts?
...... YesNoYesNo
f.Are any business or personal assets restricted or pledged
forany purpose (i.e.collateral fora loan, etc.)?
...... YesNoYesNo
g. Were you bonded in the past - by whom?
...... YesNo
YesNo
Explainall"yes" answers fullybelowor attach explanation
AGENCY DATA
Agency NameLiberty Agency Code
SWIFT BOND APPLICATION INDEMNITY AGREEMENT
Indemnitorrepresentsthat allstatementsmadeintheApplicationaretrueandmadewithoutreservationtoinduceSuretytoextendsuretycreditonitsbehalfinrelianceuponthe Agreement;confirmsthatithasamaterialandbeneficialinterestintheprovisionofeachBondrequestedincludingBondsrequestedinotherApplicationsorasotherwise permitted; and hereby agrees with Surety as follows:
1. Definitionsapplicabletothe IndemnityAgreement:
Agreement: This Indemnity Agreement, and any other agreement between Indemnitor and Surety executed forSurety's benefit.
Bonds: Anyandallbondsorotherobligations,renewals,extensions,replacementsandsubstitutionsthereof,issuedpriortooraftertheexecutionofthisAgreement,and issued foror atthe request ofIndemnitor.
Indemnitor: Eachandalloftheundersigned,theircurrentandfuturesubsidiariesandaffiliates,andanypersonorbusinessentityaddedbywrittenamendment (towhich amendmentIndemnitorsherebyagreemaybeexecutedsolelybythat newIndemnitor),jointandseverally,whetheractingaloneorinjointventurewithothers,and,astoall ofthem,their successors, assigns, and heirs.Where used in the Agreement, the term applies toIndemnitors individually and collectively.
Loss:Claims,losses,liability,damagesofanytype(includingpunitive),costs,fees, expenses,suits, orders,judgments,oradjudicationswhatsoever,andinterestthereupon fromthedateuponwhichSuretyincursaLossorpostsreservesinanticipationof Loss,whichSuretymayincurinanymannerrelatingto theextensionof suretycredit, including the enforcement ofthe Agreement.
Surety:The Surety will be a bond company chosen by broker, including anymemberoftheLibertyMutualGroupforwhichLibertyMutualSuretyunderwritessuretybonds,severallynot jointly; their respective successors and assigns; any co-surety, reinsurer, or surety thatissues a Bond atthe request ofSurety.
2. Premiums: Topay premiums when due, and todeliver evidence satisfactory toSurety,ofthe release ofall liability;
3.Indemnity:Toexonerate, indemnify and hold harmless Surety from and against all and all Loss;
4.Place inFunds:Toplace Surety in funds immediately upon demand in the amount Surety deems necessary toprotect itself from any Loss or potential Loss, Surety
having the right touse all or part ofthe funds in payment, settlement, or reimbursement toitself ofany Loss;
5.Assignment: (I)Scope: Indemnitor assigns and pledges toSurety as security, a lien and security interest in its interest, title,and rights in and growing out ofthe
following:(a)anybondedcontract, anyagreementrelatedtoabondedcontractincludinganylabororsupplysubcontractandanybondinsupportthereof,andanyaction, claimordemandwhichIndemnitormayacquireagainstanypartytothesecontractsorotherwiserelatedtoabondedcontract;(b)allmachinery,supplies,equipment,plant, toolsandmaterialswhichareormaybeonthesiteofthebondedcontract,includingmaterialspurchased,beingconstructed,instorage,orintransit;(c)totheextentSurety determinesnecessarytofulfillorcompletebondedobligations:licenses,patents,copyrights,tradesecrets,limitedpartnershipandgeneralpartnershipinterests;(d)any fundsthataredueormaybecomedueonabondedcontractorothercontract,includingretentionandrecoveryfromclaims.(II)ExerciseofRightsbySurety:The assignmentiseffectiveuponthedateofthisIndemnityAgreement,buttheSuretymayexerciseitsrightsonlyifIndemnitor:(i)breachesabondedcontract, Bond,orthe Agreement;(ii)isdeclaredindefaultbyaBondobligeeorapaymentbondclaimismade;(iii)makesanassignmentforthebenefitofcreditors;anapplicationforthe appointmentofatrusteeorreceiverismade;orfilesanapplicationundertheBankruptcyCodeorsimilarlawsofanystate;(iv)issubjecttoanyproceedingwhichdeprivesit of theuseof thematerialsreferredto in(b),above;(v)isdebarredorotherwisedeclaredineligiblefor publicwork;and(vi)ifanindividual,anIndemnitor'sdeath, disappearance, incompetence, insolvency, conviction ofa felony or imprisonment.
6.Security Agreement: This Agreement shall constitute a Security Agreement tothe Surety and a Financing Statement,both in accordance with the Uniform CommercialCodeof everyjurisdictioninwhichsuchCodeisineffect,butthefilingorrecordingof theAgreementshallbesolelyat Surety'soption,andthefailureto fileshall not release or impair any Indemnitor's obligations under the Agreement or otherwise, nor shall it be in any manner in derogation ofany ofthe Surety's rights.
7.PowerofAttorney: Indemnitor irrevocably appoints Surety as Attorney-in-fact with the full right and authority, but not the obligation, toexercise the rights of Indemnitor assignedtoSuretyabove,andtoexecuteonbehalfofandsignIndemnitor'snametoanydocumentdeemednecessarybySuretytogivefulleffecttothe purposesoftheAgreement.IndemnitorherebyratifiesallactstakenbySuretyasattorney-infact,acknowledgesthatthispowerofattorneyisapowercoupledwithan interest, and agrees tohold harmless Surety from any claims, damages, loss or expense incurred by its use.
8. Surety's Rights:(a) Loss: Surety has the right atits sole discretion topay or settle any Loss and the sworn voucher ofpayment signed by Surety shall be prima facie evidenceof Indemnitor'sliability;(b)Suits:Suretymaybringseparatelawsuitsto recoverundertheAgreement,anddoingsoorrecoveringbywayof judgmentuponacause ofactionshallnotprejudiceorbarthebringingofsuitsuponothercausesofaction,whenevertheymayarise;(c)Other Agreements:AnyrightsSuretymayhaveoracquire againstIndemnitorundertheAgreementareinadditionto andnotinlieuof anyrightsaffordedSuretyunderanyotheragreementrelatedto suretycredit;and,ifSurety executesanyBondwithaco-suretyorreinsuresallorpartof aBond,allthetermsof theAgreementshallapplyandoperatefor thebenefitof theco-suretyandreinsurer,as theirinterestsmayappear;(d)DeclineorCancelBonds:SuretyshallhavetherighttodeclineorcancelaBondatanytime, freeofclaimforlossordamagebyIndemnitor, andSuretyshallbeundernoobligationto discloseitsreasonstherefore,theprovisionsof anylawto thecontrarybeingherebywaived;(e)Non-waiver:theexercise,delayor failurebySuretytoexerciseanyright,remedyorpowerwhatsoevershallnotprecludeanysubsequentexerciseorwaiveroftheseoranyotherrights,remediesbythe Surety.
9.
10.
This Application may be executed in multiple counterparts, each being deemed an original but all ofwhich constitute one and the same agreement.
ThisDocument: Ifthe execution ofthis Agreement shall be defective forany reason, such defect or invalidity shall not affectthe validity ofthe Agreement as toany
otherIndemnitor. Ifanyprovisionisheldinvalid,theremainingprovisionsshallretaintheirfullforceandeffect. Afacsimile,photocopy,orelectronicreproductionshallbe considered an original and shall be admissible in a court oflaw tothe same extent as an original.
11.
Termination:Indemnitor may terminate its indemnity obligations under this Indemnity Agreement forfuture bonds upon twenty (20) days written notice toSurety,sent
by registered or certified mail.
SuchnoticeshallnotmodifyordischargeIndemnitor'sobligationsforBondsauthorized,executed,orcommittedtobySuretypriortothedischargedate(includingrenewals, extensions, modifications and substitutions), or forfinal Bonds issued forbid bonds issued prior tothe discharge date.
12.
Effective Date: This document shall be effective on the date it is executed by one or more Indemnitors.
ThisIndemnityAgreement isdated: ,.
Bysigningbelow,eachindividualsigningonbehalfof abusinessentityrepresentsandwarrantsthatheorsheis dulyauthorizedbythebusinessentityto bindit to thisIndemnityAgreement:
NOTE: Personsauthorizedtosignonbehalfofeachbusinessentity:SoleProprietor-Owner;Partnership-ManagingPartner;LimitedPartnership-GeneralPartner;CorS Corporation. - President; Limited Liability Company - Managing Member
Indemnitor(Business): Company Name:
Authorized
Signature: PrintedName:
Indemnitor(Individual): Signature:
PrintedName: Indemnitor(Individual): Signature:
PrintedName: Indemnitor(Individual): Signature:
PrintedName:
Indemnitor(Spouse): Signature:
PrintedName: Indemnitor(Spouse): Signature:
PrintedName: Indemnitor(Spouse): Signature:
PrintedName:
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