An Application Bond form is a critical document that serves various purposes across multiple fields, incorporating components like personal identity, business information, and financial statements. Designed to be versatile, it caters to a broad spectrum of needs, from public officials and fidelity bonds to probate and court bonds. The form meticulously collects applicant data, such as name, social security number, marital status, and contact details, ensuring thorough identification. It delves into business specifics for individuals, partnerships, corporations, and limited liability companies, requiring detailed financial disclosures to assess the applicant's financial stability. This assessment is crucial for the surety to estimate the risk involved in providing a bond. The form also outlines the conditions under which indemnity is required, emphasizing the importance of accuracy and full disclosure. The indemnity agreement is designed to protect the surety from potential losses, making clear the obligations of the applicant, such as premium payments and the provision of conclusive evidence terminating liability. Moreover, it provides guidelines for various entities on how to complete and sign the form, ensuring that all necessary information is provided accurately. This form is not just a formality but a comprehensive tool that facilitates the understanding and management of the risks associated with issuing bonds.
| Question | Answer |
|---|---|
| Form Name | Application Bond Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | cna form 10, cna surety bond online, surety application for bond, cna surety application for bond |
COMPLETE APPLICABLE SECTION ON REVERSE
Section Public Official . . . . . . . . . . . . 1
Fidelity . . . . . . . . . . . . . . . . . 2 Probate . . . . . . . . . . . . . . . . 3 Referee, Receiver, etc. . . . . . 4 Court . . . . . . . . . . . . . . . . . . 5 License . . . . . . . . . . . . . . . . 6 Lost Securities . . . . . . . . . . . 7
|
Individual |
|
www.cnasurety.com |
Partnership |
|
Form 10 |
Corporation |
|
Limited Liability Company |
||
|
||
APPLICATION FOR |
Limited Liability Partnership |
Applicant Name (Exactly as shown on License or Bond) Please print or type |
|
|
|
|
Social Security # |
|
Date of Birth |
Married |
|
|
||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Single |
|
|
Residence Address |
(Street and Number) |
(City) |
(State) |
(Zip) |
|
(Telephone #) |
(Fax #) |
(Email Address) |
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
Business Address |
(Street and Number) |
(City) |
(State) |
(Zip) |
|
(Telephone #) |
(Fax #) |
(Email Address) |
||||||||
|
|
|
|
|
|
|
|
|
|
|||||||
Occupation or Business |
How long so engaged? |
Previous Surety |
|
|
|
Yes |
|
No If yes, give name and reason for change. |
||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Type of Bond
Amount of Bond
Effective Date
Complete Name and Address of Obligee
FINANCIAL STATEMENT as of
|
|
|
|
|
|
|
|
Check applicable section on the reverse side to see whether a financial statement is necessary. |
|
|
|
|
|
||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
Check one: |
|
|
Business Financial Statement |
|
Personal Financial Statement |
|
|
|
|
|
||||||||||||||||
|
|
|
|
|
|
|
|
|
ASSETS |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
LIABILITIES |
|
|
|
|
|
||
Cash (List Banks) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Accounts Payable |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Taxes due & accrued |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
Stocks + Bonds — Describe |
|
|
|
|
|
|
|
|
|
|
Notes Payable to Bank |
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Notes Payable to Others (Describe) |
|
|
|
|
|
|
|
|||||||||||
Notes Receivable — Describe |
|
|
|
|
|
|
|
|
|
Mortgage on Real Estate |
|
|
|
|
|
|
A |
|
|
|
|||||||||||||||
Merchandise or Material in Stock |
|
|
|
|
|
|
|
|
Mortgage on Real Estate |
|
|
|
|
|
B |
|
|
|
|||||||||||||||||
Accounts Receivable |
|
|
|
|
|
|
|
|
|
|
|
|
Other Liabilities — Describe |
|
|
|
|
|
|
|
|
|
|
||||||||||||
Real Estate, Homestead |
|
|
|
|
A |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
Real Estate, Investment |
|
|
|
|
B |
|
|
|
|
TOTAL LIABILITIES |
|
|
|
|
|
||||||||||||||||||||
Furniture and Fixtures |
|
|
|
|
|
|
|
|
|
|
|
Capital Stock (Paid in) |
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||
Other Assets - Describe |
|
|
|
|
|
|
|
|
|
NET WORTH OR SURPLUS |
|
|
|
|
|
|
|
||||||||||||||||||
TOTAL ASSETS |
|
|
|
|
|
|
|
TOTAL Liabilities and Net Worth |
|
|
|
|
|
||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Gross Sales - Two Years Ago |
|
|
Last Year |
|
|
Net Income - Two Years Ago |
|
|
Last Year |
|
|||||||||||||||||||||||||
INDEMNITY
The undersigned applicant and indemnitors hereby request Western Surety Company, Universal Surety of America, Surety Bonding Company of America and any affiliated company, their successors or assigns (with such company/companies referred to herein as the "Company") to become their surety. The undersigned hereby certify the truth of all statements in the application, authorize the Company to verify this information at the time of application and as needed, on an ongoing basis and to obtain additional information from any source, including obtaining credit reports at the time of application, in any review or renewal, at the time of any potential or actual claim, or for any other legitimate purposes as determined by the Company in its reasonable discretion, and jointly and severally agree:
( 1) To pay premiums, including renewal premiums and any other charges, to the Company or its agents, when due,
(2) To completely INDEMNIFY the Company from and against any liability, loss, cost, attorneys' fees and expenses whatsoever which the Company shall at any time sustain as surety or by reason of having been surety on this bond or any other bond issued for any applicant and or indemnitor, or for the enforcement of this agreement, or in obtaining a release or evidence of termination under such bonds, regardless of whether such liability, loss, costs, damages, attorneys' fees and expenses are caused, or alleged to be caused, by the negligence of the Company,
( 3) To furnish the Company with satisfactory and conclusive termination evidence that there is no further liability on this bond or any other bond issued for applicant,
( 4) Upon demand by the Company for any reason whatsoever, to deposit current funds with the Company in an amount sufficient to satisfy any claim against the Company by reason of such suretyship,
(5) That the Company shall have the right to handle or settle any claim or suit in good faith and the Company's decision shall be binding and conclusive on the undersigned. An itemized statement of loss and expense incurred by the Company, shall be prima facie evidence of the fact and extent of the liability of the undersigned to the Company,
( 6) That the Company may decline to become surety on any bond and may cancel or amend any bond without cause and without any liability which might arise therefrom,
(7) That the Company shall, without notice, have the right to alter the penalty, terms and conditions of any bond issued for undersigned, and this agreement shall apply to any such altered bond. The liability for the undersigned shall not be affected by the failure of the undersigned to sign any bond, nor any claim that other indemnity or security was obtained, nor by the release of any indemnity, nor the return or exchange of any collateral obtained and if any party signing this agreement is not bound for any reason, this agreement will still be binding on each and every other party
(8) That if a contract or performance bond is issued hereunder, the undersigned hereby assign to the Company any monies now due or hereafter becoming due under the contract, including all deferred payments and retained percentage, supplies, tools, plants, equipment and materials due or used on the contract,
(9) At the Company's discretion, this indemnity agreement shall be governed in all respects by the laws of the State of South Dakota and the undersigned applicant and indemnitors consent to the jurisdiction of the courts of the State of South Dakota and the United States District Court for the District of South Dakota in all actions or proceedings arising from or relating to this indemnity agreement,
(10)That this indemnity may be terminated by the undersigned, or any one or more parties so designated, upon written notice sent registered mail to the office of the Company at Sioux Falls, South Dakota 57104, of not less than twenty (20) days. In no event, shall any termination notice operate to modify, bar, discharge, limit, affect or impair the liability of any party hereto, for any bonds, undertakings and obligations executed prior to the date of the Company's receipt and notice of such termination
(11) In the event of any payment by the Company, to pay the Company interest on such amounts |
Signed this |
|
day of |
|
, |
at the highest legal rate from the date such payments are made. |
|
|
|
|
|
Agency
Address
Street
City |
State |
Zip |
Agent's Code
AGENT'S RECOMMENDATION
Your recommendation will be helpful and may be the difference between getting a refusal or having the bond written. Tell us what you know and think of the applicant.
"Indemnitor"
"Indemnitor"
"Indemnitor"
Note: Personal indemnitors should print and sign their names before the word "indemnitor" in their
own handwriting, e.g. John Doe |
"Indemnitor" |
AGENT: Check here if this correspondence was previously faxed or emailed to CNA Surety.
Form
IMPORTANT NOTICE
Please discuss with the principal the potential use of personal credit history to facilitate the underwriting review process.
1
2
PUBLIC
OFFICIAL
BOND
NO FINANCIAL STATEMENT
NECESSARY.
HAVE PRINCIPAL SIGN APPLICATION IF $75,000
OR MORE.
FIDELITY
BOND
NO FINANCIAL STATEMENT
NECESSARY.
Net Worth: |
|
Elected |
|
|
|
|
|
Date: |
|
Term of Office: |
|
|
Premium will be paid: |
|
|||||||||||||||||||||
$ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Annually? |
|
|
|
for term? |
|
||||||||||
|
Appointed |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
Title of Position |
|
|
|
|
|
|
|
|
|
|
Main Sources of Organization's Funding |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Purpose or Function of Organization |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||
Annual Salary |
Will applicant sign |
|
|
|
Is countersignature required? |
|
|
Yes |
|
No |
|
Regular audits? |
|
|
Yes |
|
|
No |
|||||||||||||||||
|
checks? |
|
Yes |
|
No |
By whom? |
|
|
|
|
|
|
|
|
By whom? |
|
|
|
|
|
|
||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Are bank accounts reconciled by someone not authorized to deposit |
Ever discharged from any employment? |
|
|
Yes |
|
|
|
|
No Why? |
|
|||||||||||||||||||||||||
or withdraw from the accounts? |
|
Yes |
|
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Last position held? |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
How long in present |
|
|
|
Applicant's net worth: |
|||||||||||||||
Reason for leaving? |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
position? |
|
|
|
|
|
|
|
$ |
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Name of deceased (Ward) |
Date of death |
Date of appointment (If over 6 |
|
|
|
|
|
|
|
months, please explain delay.) |
|
|
|
|
|
|
|
|
|
|
|
|
|
3
4
5
6
7
PROBATE
BOND
NO FINANCIAL STATEMENT
NECESSARY.
HAVE PRINCIPAL SIGN
THIS APPLICATION.
REFEREE'S
RECEIVER'S
TRUSTEE'S
BOND
NO FINANCIAL STATEMENT
NECESSARY.
HAVE PRINCIPAL SIGN
THIS APPLICATION.
COURT BOND OTHER THAN 3 AND 4
FINANCIAL STATEMENT
NECESSARY.
HAVE PRINCIPAL SIGN
THIS APPLICATION.
LICENSE AND PERMIT BOND
FINANCIAL STATEMENT NECESSARY WHERE STATE IS THE OBLIGEE.
HAVE PRINCIPAL SIGN
THIS APPLICATION.
LOST SECURITIES/
CERTIFICATE
OF TITLE BOND
FINANCIAL STATEMENT
NECESSARY.
HAVE PRINCIPAL SIGN
THIS APPLICATION.
Has applicant had prior possession of estate assets? |
|
Yes |
|
No If yes, please explain. |
Name and address of attorney (If none, do not write the bond; submit it to our underwriters.)
Will the attorney remain involved throughout the |
Assets of estate or trust (describe) |
|
|
|
|
|
|
|
||||||||||||||||||||||
duration of this estate? |
|
Yes |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Name, age, and health status of |
|
|
|
|
|
|
|
|
Applicant's relationship to |
|
Applicant's net worth: |
|||||||||||||||||||
|
|
|
minor(s) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
deceased |
|
|
$ |
|
|
|
|
|||||
|
|
|
incompetent |
|
|
|
|
|
|
|
|
|
|
|
|
|
ward(s) |
|
|
|
|
|
|
|
||||||
Are guardianship funds to be used for support of ward? |
|
|
|
|
|
|
What is the source of the guardianship funds? (If an insurance settlement, |
|||||||||||||||||||||||
|
|
|
|
Yes |
|
No Approximately how much per month? |
|
|
|
|
|
|
|
do not execute the bond; instead refer it to an underwriter.) |
|
|||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||
(Please |
send |
copy of court order authorizing monthly expenditures.) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||
Who are the heirs of this estate? |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Has anyone objected to the |
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
applicant's appointment as fiduciary? |
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Yes |
|
No |
Will any going business (excluding farms) of the estate be continued |
|
|
|
Is this bond required on the demand of an interested person? |
|
|||||||||||||||||||||||||
by fiduciary? (If yes, send a copy of court order.) |
|
|
Yes |
|
No |
|
|
|
|
|
Yes |
|
No Who? |
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Name and address of court:
What is the applicant's experience in handling fiduciary responsibilities?
Plaintiff |
Name and address of principal's attorney |
|
|
|
|
||
|
|
|
|
|
|
|
|
Defendant |
Name and location of Court |
|
|
|
Applicant's net worth: |
||
|
|
|
|
|
|
|
$ |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Name and location of Court |
|
Name of Defendant |
|
|
|||
|
|
|
|
|
|
||
Name and address of attorney |
|
If an Injunction or Restraining Order bond, does applicant |
|||||
|
|
anticipate a foreclosure or collection action against him? |
|||||
|
|
|
Yes |
|
No |
If so, submit for underwriting. |
|
Explain purpose of bond (submit copy of relevant documents)
Net worth: |
|
|
General liability insurance carried? |
|
Yes |
|
|
No |
State license number assigned to applicant, if applicable: |
|||||||||||||||||||||||||||
$ |
|
|
|
|
|
(Give limits) |
|
|
|
|
|
|
|
# |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||
Serial Number and description (Please submit a copy or sample of the |
|
|
|
Date of instrument |
Payable to applicant only? |
|
|
|
Yes |
|
|
|
No |
|||||||||||||||||||||||
form it was on.) |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
If not, who is it payable to? |
|
|
|
|
|
|
|
|
|
|
|||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Are securities endorsed? |
Describe manner of loss |
|
|
|
|
|
|
|
|
Has notice of loss been given? |
|
|
|
Yes |
|
|
|
|
No |
|||||||||||||||||
|
|
Yes |
|
No |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
When? |
To Whom? |
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
If registered, in whose name? |
|
If a check, has payment been stopped? |
|
|
|
If a deed of trust or note, has either been involved in a lawsuit? |
||||||||||||||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
No If so, when? |
|
|
|
|
Yes |
|
|
No Was a judgment obtained? |
|
|
Yes |
|
|
No |
||||||||||
|
|
|
|
|
|
|
|
|
Yes |
|
|
|
|
|
|
|
|
|
|
|
||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Vehicle Make |
|
|
|
|
|
|
Vehicle Model |
|
|
|
|
|
Vehicle Year |
|
Vehicle VIN |
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Is there a lien or lien holder? |
|
|
Yes |
|
No If yes, list and explain. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
CNA is a registered service mark, trade name and domain name of CNA Financial Corporation. No part of this material, including the CNA Surety logo, may be reproduced
without written permission from CNA Surety Corporation.
P.O. Box 5077 |
|
Sioux Falls, South Dakota |
www.cnasurety.com |
|
|