Form Application FMC NVOCC Bond


Application for FMC/NVOCC Bond

APPLICANT IS (select one):

If other, please describe:

BASIC INFO:

Applicant Name (Principal) *:

Name to appear on bond, if different from Applicant:


Principal's Address:
Street:

City, State:

Zip Code:


Principal's Contact Number:
Phone:

Fax:


Are there any other locations?
If so, please attatch a complete listing of all addresses.

BUSINESS/OCCUPATION INFO

Applicant's Business Description or Latest Occupation:

Principle Owner’s Name:
(If Partnership or LLC list all owners on separate sheet)


Address:
Street:

City, State:

Zip Code:


U.S. Citizen?


Spouse's Name


Bond Amount

Desired Effective Date of Bond:


Underwriting Questions (required for all applicants):

1) Does the Applicant have any other Surety bonds in force?

2) Has another Surety Company Declined to write this or any previous bond

3) Have you ever had a bond involuntarily terminated or cancelled?

4) Has there ever been a claim or legal action against any bond executed on your behalf?

5) Do you or any of your companies have any pending lawsuits, unsatisfied judgments or liens?

6) Have you or any of your companies declared bankruptcy or become insolvent?

7) Have you or any of your companies been the subject of any legal or administrative proceedings resulting in disciplinary action?

8) Have you ever been convicted of a felony?

9) Has the Applicant continuously been in business under the current name and ownership for at least 3 years?

10) If the Applicant is a business, has it been in business at the same location for at least 3 years?

11) If the Applicant is an individual, have you resided at your current address for at least 3 years?

12) Do you carry any insurance that affirmatively responds to the bonded obligation?

If you answered Yes to any of the above questions, please attach a detailed 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) attach personal financial statement(s) for owner(s).

If there is a current FMC/NVOCC bond in effect, attach a copy of that bond w/all amendments.

Reason for switching?

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

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