In CA, DBA: Griffin Insurance Services, CA License #0G66558
800.562.8095 Phone . 425.453.8696 Fax
PO Box 3867 . Bellevue, WA 98009 /
Bellevue. Portland. Spokane.
Please type or complete with a BLACK pen. Thank you!
Agency: / Contact:Contact by: / Fax: E-Mail:
BOND INFO (MUST COMPLETE IN FULL)
BOND TYPE:
Contractor License Bond w/New Licensee*$12,500
Contractor License Bond - $12,500
Contractor License Bond Qualifying Individual (BQI) $12,500***
***If RME/RMO, Qualifying Individuals Name:
Contractor License Bond Roofer $12,500
Contractor License Bond Swimming Pool $12,500 / *NEW LICENSEE – CONFIRM THE FOLLOWING:
As used herein, when the applicant is a corporation, limited liability company, partnership or sole proprietorship, the term “applicant” shall include any and all individuals owning any ownership interest in such entity. I am confirming that I have verified that the applicant has never held a prior contractor’s license and does not have a Swimming Pool Classification (C-53) and/or Roofing Classification (C-39) with the CSLB.
True False**- Applicant has never held or been an officer, partner or member
of a company that has held a California Contractors License
True False**- Applicant does not have a Swimming Pool Classification (C-53)
True False**- Applicant does not have a Roofing Classification (C-39)
**If any False, please refer to California Contractors License Application and confirm Bond Type required for your Applicant.
CONTRACTOR’S APPLICATION FEE NUMBER or LICENCE NUMBER:*Required
APPLICANT INFO
Business Name:
Business Address:
Form of Business: Individual Partnership Corporation LLC / Business Phone #--
Owner Last Name: / Social Security:--
Owner First Name: / Date of Birth:
Owner Middle Name: / Driver’s License Number:
Home Address: / Home Phone/Cell:
Spouse’s name and SS#:
GUS CREDIT CHECK DISCLAIMER
I have discussed the Underwriting Process with my Client. My client is aware that his/her personal Credit History will be part of the underwriting process. We also understand that all Owners of a Partnership, LLC and/or Corporation (even silent members/shareholders) will be subject to approval and have been provided for underwriting review. By providing the personal information above, my client has provided GUS his/her consent to begin the Underwriting Process. GUS is not provided a copy of the personal credit report nor able to discuss any item(s) that may appear on the applicant’s report. All Underwriting decisions are provide by the qualifying Carrier and are final. All inquires about an individual’s personal credit history should be made directly to the Credit Reporting Companies themselves.
*Certain markets require the applicant’s signed consent in order X______
to obtain credit information. We can proceed without the signature, Applicant’s Signature*
but we will not be able to obtain quotes from all possible markets.
GUS-CACLB-1s (10/11)