Lost Securities Surety Application

Home Office: Columbus, Ohio
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

Lost Securities Surety Application - Maryland

Agency Name & Address: / Bond Number:
Applicant(Principal) Name & Address: / Social Security No. or Tax ID No.:
Applicant is:
Individual C-Corp. S-Corp. L.L.C. Other: / Is Individual a U.S. Citizen?
Yes No
Applicant Phone No.: / Contact Name if Applicant is a Business:
If Applicant is a Business, Year Business Started: / State of Incorporation:
Applicant’s Business Description or Most Recent Occupation:
Applicant Billing Address if Different than above:
Co-Applicant(Principal) Name & Address(if any): / Social Security No. or Tax ID No.:
Co-Applicant is(if any):
Individual C-Corp. S-Corp. L.L.C. Other: / Is Individual a U.S. Citizen?
Yes No
Obligee Name & Address (Party Requiring Bond):
Attorney Name & Address that is representing the Principal:
Bond Amount:
$ / Bond Effective Date: / Bond Term, if known:

List Applicant(s) Assets and Liabilities:

ASSETS / LIABILITIES
Cash: / Credit Cards:
Securities: / Mortgage:
Real-Estate: / Other:
Other: / Other:

Provide the following

Value of the Lost Instrument:
Complete Description of the lost Instrument:
If Securities is Registered, Name of the Registered owner:
State when and how you became the owner of the Instrument:
Provide the details of how and when the Instrument was lost or first discovered to be lost

Underwriting Questions

1.Do you have any other Surety bonds currently in force?...... Yes No

2.Has another Surety declined to write this or any previous bond?...... Yes No

3.Are you currently involved in any litigation?...... Yes No

4.Have you ever been convicted of a felony?...... Yes No

5.Have you or any of your companies declared bankruptcy or become insolvent?...... Yes No

6.Is there a Obligee specific bond form required (If “Yes,” Attach a copy)?...... 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.

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 Nationwide Mutual InsuranceCompany (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 Vice-President, 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 knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

IN WITNESS WHEREOF, we have signed and sealed this Agreement to be effective the day 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 section if 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:

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