Home Office: Scottsdale, Arizona
Surety Administrative Office:
7 World Trade Center, 37th Floor
250 Greenwich Street
New York, NY 10007-0033
1-888-800-0147 • Fax (480) 905-5454
License & Permit/MiscellaneousCommercial Surety Application – Maryland
Agency Name & Address: / Bond Number:Company or Applicant Name (exactly as it appears on your license and/or will appear on the bond): / Social Security No. or Tax ID No.:
Company or Applicant Address:
Applicant Type (Individual, Corporation, LLC, Partnership, Other): / Total Amount of Bonds Outstanding:
$ / Professional License No. :
Contact Name if Applicant is a Business: / Contact E-mail:
Year Business was Started: / State of Incorporation:
Name of Individual Signing Bond(Registrant, Responsible Party,
Officer): / Individuals Title: / No. Years Experience:
Name & Address of Owner/Spouse (Indemnitor): / Social Security No.:
Name & Address of Owner/Spouse (Indemnitor): / Social Security No.:
Name & Address of Owner/Spouse (Indemnitor): / Social Security No.:
Name & Address of Owner/Spouse (Indemnitor): / Social Security No.:
Type of Bond Required: / Bond Amount:
$
Bond Effective Date: / Bond Term if Known:
Obligee Name & Address(Party Requiring Bond):
Underwriting Questions
1.Do you have any other Surety bonds currently in force?...... Yes No
2.Are you or any owners or officers of the company, if the application is a company,currently involved in anylitigation?...... Yes No
3.Has there ever been a claim or legal action against any previous bond executed on your behalf?...... Yes No
4.Has another Surety declined to write this or any previous bond for you?...... Yes No
5.Have you ever had a bond involuntarily cancelled or terminated?...... Yes No
6.Have you ever failed in business or caused a loss to a Surety?...... Yes No
7.Have you or any of your companies declared bankruptcy or become insolvent?...... Yes No
8.Have you ever been convicted of a felony?...... Yes No
9.Has there been any change in the company name or ownership in the last three years?...... Yes No
If you have answered “Yes” to any of the questions listed above, please provide an explanation below and if necessary, attach supporting documentation.
10.Is there a Obligee specific bond form required?(If “Yes,”Attach a copy)...... Yes No
11.Does the bond guarantee payment of taxes, wages, benefits or any other type of financial obligation?...... Yes No
a.If “Yes,” and the Applicant is a legal entity, please attach a current corporate financial statement...... Attached
b.If “Yes,” and the Applicant is an individual, please attach a current personal financial statement...... Attached
12.Does the Bond guarantee the performance of a specific contract or agreement?(If “Yes,” Attach a copy of the requirement)...... Yes No
13.Does the Bond guarantee any type of environmental exposure?(If “Yes,” Attach a copy of the requirement)...... Yes No
Indemnity Agreement
The undersigned Applicant and Indemnitor(s), (all hereinafter called the Indemnitor(s))acknowledges that all information is complete and correct and is given to induce the insurance company and its agent to execute the bond applied for. It is understood that false information may constitute misrepresentation or fraud. Authorization is given to investigate the credit, character, capacity and capital of the Indemnitor(s) for bonding purposes.
Should the National Casualty Company (hereinafter called the Company) execute or procure the execution of the suretyship hereinbefore applied for, or other suretyship in lieu thereof or in connection therewith, the Indemnitor(s) do, in consideration thereof, jointly and severally and for each other undertake and agree.
That the statements contained in the foregoing application are true.
That the Indemnitor(s) will pay the Company, at its office in New York, New York, in advance, in each and every year, the premiums for such suretyship, or any renewal, extension, modification or continuation thereof, or Consent of Surety, requested or assented to by the Indemnitor(s), and until the Indemnitor(s) shall serve upon the Company competent written legal evidence satisfactory to it of its final discharge from such suretyship and all liability by reason thereof. And the Indemnitor(s) hereby agree that the voucher or other evidence of any payment made by the Company by reason of such suretyship be competent evidence of such payment and the propriety thereof, and of the Indemnitors’ liabilitytherefor to the Company, and do hereby further bind themselves, their heirs, executors, administrators, successors and assigns, to indemnify and save the Company harmless, and on demand to pay it any and all claims, demands, loss and damages of every nature and kind, as well as all legal and other costs, counsel fees and expenses which the company shall at any time sustain, directly or indirectly, by reason or in consequence of such suretyship, or any renewal, extension, modification or continuation thereof, or Consent of Surety or additional suretyship, whether before or after legal proceedings by or against the Company, and whether with or without notice thereofto the Indemnitor(s). Payment by the Indemnitor(s) to the Surety should be made as soon as liability exists or is asserted, regardless of whether the Surety shall have made payment therefor, and shall be equal to the amount of the reserve set by the Surety in connection with the claim. Failure to make the payment requested by the Surety shall be a breach of this agreement. The Surety shall have the right to settle, adjust or compromise any claim related to the bonds and any amount paid in connection therewith shall be repaid by the Indemnitor(s) to the Surety, provided that in the event that the Indemnitor(s) object to the settlement, adjustment or compromise proposed by the Surety, and desire that the claim be litigated, the Surety shall have the right to demand from the Indemnitor(s) and receive in advance of denying the claim and litigating it, such cash or other security as is satisfactory in kind and amount to the Surety to be used to pay any judgments, awards, and expenses (including attorney’s fees) that may be rendered against or incurred by the Surety in connection with the claim. The Indemnitor(s) will, on the request of the Company, procure the discharge of the Company from said suretyship, and all liability by reason thereof, and any and all renewals and extensions of the same. The Company shall not be required to remove or join in the removal of any action arising upon the obligation referred to or in any way connected therewith from the State Court to the Federal Court, if there by any law practice prevailing in the State in which such action is brought fixing any penalty for such removal or providing for the revocation of the license to transact business in said State of a foreign corporation applying for such removal.
The Company, and its designated agents, shall, at any and all reasonable times, have free access to the books and records of the Indemnitor(s).
The Company shall have the right at any and all reasonable times to obtain from consumer credit reporting agencies, information concerning any Indemnitor(s) credit history and to ascertain from the bank, banks, or other depository with which the Indemnitor(s) do business, the amounts standing to the credit of the Indemnitor(s), and the Indemnitor(s) indebtedness to such bank, banks, or other depository, and such bank, banks, or other depository are authorized and directed to supply the Company with such information.
That if the Indemnitor(s), or one or more of them be a corporation, it is specifically and beneficially interested in obtaining said bond and that the officer executing on its behalf is thereunto duly authorized with full power to bind said corporation in the premises.
That no change or modification of or in the terms of this agreement shall be effective unless such change or modification is in writing and signed by the President, a VicePresident, a Secretary, or an Assistant Secretary of the Company.
A facsimile signature of this document shall be deemed an original signature for any and all purposes.
FRAUD PREVENTION—WARNING
Notice to applicants: Any person who knowinglyor willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false informationin an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
IN WITNESSWHEREOF, we have signed and sealed this Agreement to be effective theday of , 20 .
If the Indemnitor is a Partnership, Corporation or LLC, complete the section below:
Witness: By:(Seal)
Printed Name: Printed Name & Title:
Only complete this sectionif there are multiple Corporate Indemnitors:
Witness: By:(Seal)
Printed Name: Printed Name & Title:
If the Indemnitor(s) is an Individual, or individual indemnity is required along with corporate indemnity, complete the section below:
Witness: Indemnitor:
Printed Name: Printed Name:
Witness: Indemnitor:
Printed Name: Printed Name:
Witness: Indemnitor:
Printed Name: Printed Name:
Witness: Indemnitor:
Printed Name: Printed Name:
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