Print This Application	General Information Questions	Fax to: 516-794-0380
Type of Bond (describe purpose)     (Attach a copy of the bond form, if available)
Bond Amount:   Effective Date of Bond:   Bond Term, if known:
Applicant is:(select 1) Individual Partnership C-Corp S-Corp LLC
Applicant (Principal):
Name to appear on Bond, if different from Applicant:
Phone:   Fax:   Email:
Applicant's Address:
Applicant's Business Description or Latest Occupation:
SS:   Fed Tax ID:   U.S. Citizen?    Yes No
Obligee - party requiring the bond (required):
Obligee Address:
Billing Address if different from Applicant's Address:

	General Underwriting Questions
Does the Applicant have any other Surety bonds in force?    Yes No
Has another Surety company declined to write this or any previous bond?    Yes No
Have you ever had a bond involuntarily terminated or cancelled?    Yes No
Has there ever been a claim or legal action against any bond executed on your behalf?    Yes No
Do you or any of your companies have any pending lawsuits, unsatisfied judgments or liens?    Yes No
Have you or any of your companies declared bankruptcy or become insolvent?    Yes No
Have you or any of your companies been the subject of any legal or administrative proceedings resulting in disciplinary action?    Yes No
Have you ever been convicted of a felony?    Yes No
(If you answered Yes to any of the above questions, please attach a detailed explanation.)

	Court: Judicial Bonds
Judgement / Claim Amount:
Type of Action:
Case Number:        Court Jurisdiction:
Attorney's name an address:
Summary of the Action:
Does the case involve a domestic dispute?    Yes No
Attach copy of Court Order, Judgement and /or other documents.    copies attached
If the bond os greater than $25,000 and the Applicant is a business,        attach a copy of the last 2 fiscal year-end financial statments.    copies attached If the bond is greater than $25,000 and the Applicant is an individual,        attach a copy of the most recent financial statment.    copy attached

The applicant(s) and the Indemnitor(s), if any, hereby authorize the company to obtain credit reports and histories and to confirm the bank balances claimed, and all other items on any balance sheet or income statment furnished until all liability of the company for any suretyship or claim obligations expire.

Indemnity Agreemant

The undersigned Applicant and Indemnitor(s) hereby certify that the foregoing declarations made and answers given, are the truth without reservation, and are made for the purpose of inducing a SURETY COMPANY for itself and its affiliates, parents and subsidiaries, hereinafter called Surety, to become Surety on a certain bond or undertaking applied for and any renewal and increase of the same or of any bond or undertaking of similar nature given in substitution or renewal thereof (all comprehended in the word "bond" or "undertaking" as herein used), and in consideration of the surety executing said bond or undertaking do undertake and agree as follows:       To pay the Surety all premiums when due and annually in advance of each renewal thereafter, until the Indemnitor(s) shall serve upon the Surety, at its said office, competent written legal evidence, satisfactory to the Surety, of it being duly discharged from such bond or undertaking. That the Indemnitor(s) hereby authorize the Surety to make such pertinent inquiry as may be necessary from financial institutions, persons, firms and corporations in order to confirm and verify information referred to or listed on this application.       The Indemnitor(s) will at all time indemnify, and keep indemnified, the Surety, and hold and save it harmless from and against any and all damages, loss, costs, charges and expenses of whatsoever kind or nature, including counsel and attorney's fees, whether incurred under retainer or salary or otherwise, which it shall or may, at any time, sustain or incur by reason or in connection with furnishing any bond or undertaking.       To deposit with the Surety on demand an amount sufficient to discharge any claim made against the Surety on this bond or undertaking. This sum may be used by the Surety to pay such claim or be held by Surety as collateral security against loss or cost on this bond or undertaking.       Regardless of the date of signature(s), this indemnity agreement is effective as of the date of execution of aforementioned bond(s) or undertaking(s) and is continuous until Surety is satisfactorily discharged from liability pursuant to the terms and conditions contained herein.

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.

WITNESS the following signatures(s) and seal(s) this    day of    , 20

If APPLICANT is an individual:

Witness:       Signature    (print above name here):       (print above name here):    Witness:       Signature    (print above name here):       (print above name here):

If APPLICANT is partnership or corporation:

Name of Firm/Corporation:       (seal)    Witness:       Signature    (print above name here):       (print above name here):             Title (print):

Third Party Indemnitors: (including personal indemnitors of S-corporations)

In consideration of the Surety executing the bond hereinabove applied for, we jointly and severally join in the foregoing indemnity agreement.

Witness:       Signature of Indemnitor (seal) (print above name here)       SS or Fed ID#    Witness:       Signature of Indemnitor (seal) (print above name here)       SS or Fed ID#    Witness:       Signature of Indemnitor (seal) (print above name here)       SS or Fed ID#

Reminder - Please make sure the application has been SIGNED, WITNESSED and DATED in the appropriate areas