Bonds Southeast, Inc. | Commercial Miscellaneous Bond Application

Bonds Southeast, Inc.

Bonds Southeast, Inc.
Contract & Commercial Surety Bonds
1030 17th Avenue South
Nashville, TN 37212
(615) 321-9700
Toll Free: 1-877-992-6637
Fax: (615) 321-9702

Application for Miscellaneous Bond

Please complete all necessary sections of this application and PRINT or SUBMIT ONLINE.

THE FOLLOWING IS REQUIRED FOR ALL BONDS REQUESTED:

Current personal financial statements on all owners, partners, or stockholders. (Form included below.)
Last fiscal year end business financial statement including: balance sheet, statement of income, and retained earnings or copy of personal or company income tax returns for the last year if the business is a proprietorship, partnership, or sub-chapter ‘s’ corporation, and there are no income statements available for the business.
All questions in the middle of the application must be answered and details provided on “yes” answers.

Additional information may be required depending upon the risk involved and the amount of the bond being requested. An underwriter will advise you of any additional requirements.

MISCELLANEOUS BOND APPLICATION

Today's Date
Name of Applicant	(As it should appear on the bond)
Address	Street CIty State Zip
Business Phone Number	( )
Business Fax Number	( )
Cell Phone Number	( )
Email
Name of Obligee
Bond Type
Bond Amount	$
Effective Date

COMPLETE THE FOLLOWING FOR ALL OWNERS

Owner #1

Name

Address

( ) Phone

- - SSN#

$ Net Worth

Owner #2

Name

Address

( ) Phone

- - SSN#

$ Net Worth

Owner #3

Name

Address

( ) Phone

- - SSN#

$ Net Worth

FIN#

How long have you been business under the current Name & Ownership?

Do any of the owners have any suits or judgments against them?

Yes No

(If YES, please explain in the comments box below)

Do you have any lawsuits pending or in the process of being filed?

Yes No

(If YES, please explain in the comments box below)

Have any of the owners ever filed bankruptcy? (Personally or Corp)

Yes No

(If YES, please explain in the comments box below)

Have you or any of the owners operated under another name?

Yes No

(If YES, please explain in the comments box below)

If so, were all the creditors satisfied?

Yes No

(If NO, please explain in the comments box below)

Have you ever had a bond cancelled or had one go into claim?

Yes No

(If YES, please explain in the comments box below)

Have you, or any of your associates ever been the subject of any proceedings resulting in disciplinary action, suspension or revocation of a license?

Yes No

(If YES, please explain in the comments box below)

Comments

INSURANCE FRAUD PREVENTION ACT NOTICE
Any person who knowingly and with intent to defraud any insurance company, who files an application for insurance containing any false information or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

The Applicant(s) and the Indemnitor(s), if any, hereby authorize the Company to obtain credit reports and histories and to confirm the bank balances claimed, and all other items on any balance sheet or income statement furnished until all liability of Company for any suretyship obligations expires.

The undersigned warrants the answers and information given herein to be true, and in consideration of the Company executing the bond or undertaking herein applied for do hereby agree as follows: To pay the initial premium and the annual premium thereafter, until the Company is furnished with conclusive evidence of the termination of its liability; To furnish such evidence and copies of such papers concerning the bond or undertaking which the Company in its discretion desire; To indemnify and keep indemnified the Company and hold and save it harmless from and against any and all loss or expense of whatever nature which the Company shall or may for any cause, at any time, sustain for or by reason or in consequence of the Company having executed said bond or undertaking. The undersigned agrees that the voucher or other evidence of payment made by the Company of such suretyship shall be competent evidence of such payment and the propriety thereof, and of the undersigned's liability therefore to the Company. The undersigned further agrees that if the amount of the premium for the bond or undertaking herein applied for is not expressed above in the space intended therefore, the undersigned agrees to pay premiums computed upon the Company's current rate as of the date of bond or undertaking. The undersigned expressly waives, as to this obligation, the benefit of all exemptions, or the homestead provision, to which the undersigned is, or may be entitled to under the laws of any State of the United States.

This application and indemnity agreement bearing the signature of the Applicant(s) and Indemnitor(s) shall be valid, effective and enforceable whether received by the Company as an original or as a facsimile transmission.

Principal Name

(Owner)

Witness Name

Personal Indemnitors

(name)	(name)
(name)	(name)

Personal Financial Statement

Statement of Financial Condition As Of
Name of Applicant
Applicant's Social Security Number	- -
Applicant's Date of Birth
Name of Spouse
Spouse's Social Security Number	- -
Spouse's Date of Birth
Residential Address	Street CIty State Zip
Home Phone Number	( )

ASSETS

Cash in Banks
Notes Receivable
Accounts Receivable
Stocks/Bonds/Securities
Real Estate (Residence)
Real Estate (Investment/Other)
Cash Value Life Insurance
Personal Property
Other Assets
TOTAL ASSETS

LIABILITIES

Loans Payable (Banks)
Notes Payable
Accounts Payable
Taxes Payable
Mortgages Payable
Other Liabilities

TOTAL LIABILITIES
NET WORTH
Total Net Worth & Liabilities

INCOME

Applicant's Salary	$
Applicant's Bonus/Other	$
Spouse's Salary	$
Spouse's Bonus/Other	$
TOTAL INCOME	$

SUPPLEMENTARY SCHEDULES OF ASSETS & LIABILITIES
(NOTE: All data listed above must appear in the appropriate schedules. Insert "NONE" where appropriate.)

CASH IN BANKS:

Name of Bank	Branch / Location	Account #	Amount

NOTES & ACCOUNTS RECEIVABLE:

Debtor #1	Name Address Amount Due Date Pledged? Yes No Security
Debtor #2	Name Address Amount Due Date Pledged? Yes No Security
Debtor #3	Name Address Amount Due Date Pledged? Yes No Security

STOCKS / BONDS / SECURITIES:

Name of Stock, Bond or Security	No. of Shares	Price/Share	Market Value	Exchange & Call Sign

REAL ESTATE:

Item #1	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder
Item #2	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder
Item #3	Location / Description Year Acquired Cost Market Value Monthly Income Monthly Payment Mortgage Balance Mortgage or Lein Holder

CASH VALUE OF LIFE INSURANCE:

Name of Insurance Company	Beneficiary	Face Value	Cash Value	Loans Outstanding

OTHER ASSETS:

Description	Title Holder	Cost	Market Value	Age of Asset

LOANS PAYABLE

Name of Lender	Address	Balance Due	Amount Due in 1 Year	How Secured

ACCOUNTS & NOTES PAYABLE (Including Charge Accounts):

Payable to Whom	Address	Amount	Monthly Payment	Due Date	How Secured

TAXES PAYABLE (State & Federal):

Description	Amount	Date Payment is Due

OTHER LIABILITIES:

Description	Payable To:	Amount	Monthly Payment	Due Date	How Secured

Are you contingently liable or an endorser on any bonds or other obligations?	Yes No
Are you involved in any litigation?	Yes No
Have you filed for bankruptcy in the last 7 years?	Yes No

Enter Your Email Here:

WARNING:
This is an application for a surety bond. A surety bond is a credit relationship. A BOND IS NOT AN INSURANCE POLICY. You, the owners, partners, stockholders and all spouses will be jointly and severally liable for payment to the Surety Company for any defaults, losses or expenses incurred by the Surety under this bond.

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.