American Contractors Indemnity Company Bond Claim Details

American Contractors Indemnity Co (ACI) is a Florida-based insurer which has been offering professional liability coverage to contractors since 1949. They offer this coverage for all types of projects, including residential and commercial work. ACI provides both broad form and occurrence policies through the U.S., Canada, Bermuda, Jersey Islands, Guernsey Islands, Jersey Islands and Ireland. Their insurance can be purchased as either primary or excess coverage to protect against losses not covered by other contracts or business owners' personal assets such as stocks or bonds. The company was founded in 1949 by John A Doyle Jr., an attorney who helped shape the industry with his knowledge of risk management practices for construction companies nationwide.

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QuestionAnswer
Form NameAmerican Contractors Indemnity Co
Form Length1 pages
Fillable?Yes
Fillable fields23
Avg. time to fill out4 min 55 sec
Other namesamerican contractors indemnity company claim form, american contractors indemnity company file claim, american contractors indemnity company bond claim form, american contractors indemnity

Form Preview Example

HCC Surety Group®

601 South Figueroa Street, Suite 1600, Los Angeles, California 90017

AUTHORIZATION TO CHARGE CREDIT/DEBIT CARD

The undersigned authorizes AMERICAN CONTRACTORS INDEMNITY COMPANY, TEXAS BONDING COMPANY, UNITED STATES SURETY COMPANY or U.S. SPECIALTY INSURANCE COMPANY hereafter called HCC SURETY to charge the credit/debit card listed below. This authority is to remain in full force and effect until HCC SURETY has received written notification from me of its termination 10 days prior to the next scheduled charge date. HCC SURETY reserves all of its rights and defenses pursuant to the applicable bond(s), agreement(s) including indemnity agreement(s), the law or otherwise.

CREDIT/DEBIT CARD INFORMATION

 

CARD TYPE

 

VISA

MASTERCARD

DISCOVER

AMERICAN EXPRESS

 

 

 

 

 

 

 

 

 

 

CARD NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CARD EXPIRATION DATE

 

 

 

CARD SECURITY CODE *see below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CARDHOLDER INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CARDHOLDER NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CREDIT CARD BILLING ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Use Only (To be completed by HCC Surety)

 

 

 

 

 

 

 

 

PAYMENT DETAIL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PAYMENT TYPE

 

 

 

PREMIUM

SUBROGATION

OTHER

 

 

 

 

 

 

 

 

 

BOND/CLAIM/COLLATERAL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRINCIPAL’S NAME if different than cardholder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF HCC SURETY ASSOCIATE MONITORING REIMBURSEMENT(S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ONE TIME PAYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ONE TIME PAYMENT AMOUNT

 

 

 

AMOUNT $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECURRING PAYMENTS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL DOWN PAYMENT

 

 

 

DOWN PAYMENT AMOUNT

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECURRING PAYMENT AMOUNT include the final payment amount if different

RECURRING

$

 

FINAL PAYMENT

$

 

 

PAYMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECURRING PAYMENT DATE select a day between the 1st and 25th

DAY OF THE MONTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL NUMBER OF RECURRING PAYMENTS TO BE AUTO BILLED including the final

NUMBER OF PAYMENTS

 

 

 

 

 

payment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST SCHEDULED RECURRING PAYMENT **

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Card security code is the three digit code on the back of Visa or MasterCard or the four digit code on the front of American Express.

**The last scheduled recurring payment may be recalculated in the event that any of the recurring payments are not made as scheduled.

I hereby declare that I am the holder of the above credit/debit card. I authorize the above mentioned amounts to be charged to the credit/debit card per the terms indicated herein.

Cardholder’s signature

Date

Please submit the signed form via fax to (310) 649‐1061 or e‐mail to CCPayments@hccsurety.com.

HCCSMZZCC2012/09

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You need to complete the AGENCY ID, PRINCIPAL’S NAME if different than, NAME OF HCC SURETY ASSOCIATE, ONE TIME PAYMENT, AMOUNT $, RECURRING PAYMENTS, ONE TIME PAYMENT AMOUNT, INITIAL DOWN PAYMENT, DOWN PAYMENT AMOUNT RECURRING, FINAL PAYMENT, RECURRING PAYMENT AMOUNT include, RECURRING PAYMENT DATE select a, NUMBER OF PAYMENTS, and DATE area with the appropriate particulars.

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It's essential to note certain information inside the box Cardholder’s signature, Date, Please submit the signed form via, and HCCSMZZCC2012/09.

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