Applicant is (select one):
If selected, define other:
Applicant Name (Principal):
Principle's Physical Address line 1:
Street:
City, State:
Zip Code:
Principle's Physical Address line 2:
Street:
City, State:
Zip Code:
Mailing Address (if different), line 1:
Street:
City, State:
Zip Code:
Mailing Address line 2:
Street:
City, State:
Zip Code:
Principle's Phone Number:
Fax Number:
Are there any additional unincorporated divisions, trade names, subsidiaries or importer numbers for your company?
If so, please attach a complete listing with names, addresses and importer numbers/Customs assigned numbers.
Description of Applicant's Operations:
Importer/Customs Assigned Number:
How long in business?
Principle Owner's Name: (If Partnership or LLC list all owners on separate sheet):
Address line 1:
Street:
City, State:
Zip Code:
Address line 2:
Street:
City, State:
Zip Code:
U.S. Citizen?
Spouse's Name:
Is there an active bond on file in ANY port? If so, list which port, Customs assigned bond number, renewal date and attach a copy of the bond.
Port:
Bond #:
Renewal Date:
Desired Bond Amount:
Desired Effective Date of Bond:
Would you like a 1 or 3 year (pre-paid) billing plan? (3 year plan receives a 20% discount on years 2 & 3):
Underwriting Questions (required for all applicants):
(If you answered Yes to any of the above questions, please attach an explanation.)
Attach a copy of the last fiscal year-end financial statements. If 6-months or older, attach interim statements also.
If the principle is a new business, (less than 3 years in operation) also attach personal financial copy attached statement(s) for owner(s).
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE, OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES, AND DENIAL OF BENEFITS.
Signature:
(By typing your name, you are officially signing this form)
Date:
Print name and title here: