MAIN STREET, SUITE 330, WEST ORANGE, NJ 07052
973-731-7650 (P) 973-731-7889 (F)
CONTRACTORS SURETY APPLICATION
Please enter your name:
Name of business (Known as Principal) as name appears on tax return
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
OWNERS AND KEY PERSONNEL:
In what class of construction do you specialize in?
Annual Sales:(last 3 years)
LIST THE FOUR LARGEST CONTRACTS COMPLETED IN THE LAST 3 YEARS:
NAME OF PRESENT AND PRIOR SURETIES: Name:
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)
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
3. Are you currently on notice of a pending default (failure to perform or to make payments) on a bonded project? Yes
4. Ever filed bankruptcy? Yes
5. Ever had a criminal conviction? Yes
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
6.Have you been bonded or applied to other surety companies within the last twelve (12) months? Yes
7.Any disputes on contracts including money due to your firm in excess of 120 days? Yes
8.Any disputes with vendors or money you owe vendors/suppliers in excess of 120 day? Yes
9.Are there any past due notices for prevailing wages, labor , union benefits, or suppliers notices against your company? Yes
If yes to any of the above explain:
10.Bank Credit Line? Yes
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.
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.
Name and Title:
Name and Title:
Name of Insurance Agency:
*For a more comprehensive response, please include latest personal and business tax returns, financial statements and bank statements.