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MAIN STREET, SUITE 330, WEST ORANGE, NJ 07052
973-731-7650 (P) 973-731-7889 (F)
JBURGER@SERVICEBONDING.COM

CONTRACTORS SURETY APPLICATION
Please enter your name:

Name of business (Known as Principal) as name appears on tax return



Address: Phone:

Is the principal or its owners or family members connected with other companies as a subsidiary, parent, holding or affiliate in any way,
including prior companies? Yes No       Details:

OWNERS AND KEY PERSONNEL:
(Please Complete)
In what class of construction do you specialize in? Date Formed:
Annual Sales:(last 3 years)
Year 1: $ Year 2: $ Year 3: $

LIST THE FOUR LARGEST CONTRACTS COMPLETED IN THE LAST 3 YEARS:


NAME OF PRESENT AND PRIOR SURETIES: Name: Agent:

1. Has this principal including any member, or any prior company you were employed by or have or had ownership in (or any owner including family members)
Yes No


2. Ever received notice of default or defaulted on a contract forcing a surety to suffer a loss or pay a claim (including receiving written notice of failure to perform to pay suppliers & subcontractors) Yes No

3. Are you currently on notice of a pending default (failure to perform or to make payments) on a bonded project? Yes No

4. Ever filed bankruptcy? Yes No

5. Ever had a criminal conviction? Yes No

6. Are there any unresolved lawsuits involving applicant/principal or spouse or a related business or any unpaid judgments or liens against applicant/principal or spouse, including judgments or liens in favor of any tax authority, IRS, any state agency or vendor or any pending or prior disputes or civil litigation? Yes No

6.Have you been bonded or applied to other surety companies within the last twelve (12) months? Yes No

7.Any disputes on contracts including money due to your firm in excess of 120 days? Yes No
Amount:$

8.Any disputes with vendors or money you owe vendors/suppliers in excess of 120 day? Yes No

9.Are there any past due notices for prevailing wages, labor , union benefits, or suppliers notices against your company? Yes No

If yes to any of the above explain:


10.Bank Credit Line? Yes No
Bank Name:
Amount Available: $
LIST TOP SUPPLIERS AND SUB CONTRACTORS:




This is to certify that all of the above statements are true and correct and to the best of my/our knowledge there are no prior, pending, or notices of any defaults or claims on this or any related entity, except for what has been previously disclosed to service insurance company. The foregoing statement applies to any other or prior business(es) i/we or any immediate family member has/had ownership in.

I/we authorize the company to investigate/verify all business and personal documentation submitted with and representations made in connection with any surety request and to check my/our credit with any creditors and/or lending institutions or credit bureaus .

Errors & ommissions

I/we will verify the accuracy of all bonds and related documents and will notify service insurance company prior to their submission. I/ we understand that service insurance company is not responsible or liable for rejected bonds or any mistakes, errors or ommissions made and I/we agree to hold service insurance company harmless should a bid or bond be rejected.

Fraud statement

Any person who knowingly and with intent to defraud any insurance company (including any surety company) or who files an application for surety bonding containing any false or misleading information or conceals any fact for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.


SIGNED THIS DAY OF
Signature:
Name and Title:
Signature:
Name and Title:
Signature Agent/Broker:
Name of Insurance Agency:

*For a more comprehensive response, please include latest personal and business tax returns, financial statements and bank statements.