New York Medicare DMEPOS Bond Form - World Wide Bonding Agency

Contact Information

Contact Name *

*

Insurance Agent

Attorney

Applicant

Other

Email *

Phone Number *

Fax Number

File Upload

*If you are an insurance agent and this is your first time submitting an application to us, please include a copy of your agency license. Please Note: Multiple Files must all be uploaded at once.

Applicant Information

Applicant or Business Name (Exactly as listed with CMS) *

*

Sole Ownership

Corporation

Partnership

LLC or LLP

Business Address *

City *

State *

Zip *

NPI Number *

Effective Date *

Bond Amount *

Nature of Business: *

Pharmacy

Grocery

Medical Supply Co

Other

Total of all Revenue last year *

Total Revenue last year from Medicare *

Date of last CMS Inspection *

Any Irregularities discovered in inspection? *

Yes

No

Previous Surety? If yes, provide Surety below and reason for change. *

Years in Business? *

Year first approved by CMS? *

Please indicate if any of the following items apply to the business or any of the owners involved.

Have any lawsuits or judgments against them? *

Yes

No

Ever failed in business or declared Bankruptcy? *

Yes

No

Any unpaid IRS or state liens? *

Yes

No

Ever had their license suspended, revoked or denied? *

Yes

No

Ever been party to a surety bond claim? *

Yes

No

Had a bond declined or cancelled? *

Yes

No

Personal Information

Give the following information on each owner or stockholder, including yourself.

*If more than two owners, please fill out an additional application.

Name *

Social Security Number *

*

Single

Married

Address

City *

State *

Zip *

Telephone *

Number of years you have owned this business *

Number of years experience *

Percent Ownership % *

Value of Primary Residence *

Balance of Mortgage *

Completion of this online application constitutes permission for World Wide Agent Services, Inc. and its selected surety companies to obtain consumer information, including personal credit reports of individual applicants as well as owners and officers of business applicants, which may be used to determine bonding eligibility. Such credit reports may also be obtained at the time of any review or renewal, any potential or actual claim, or for any other legitimate purposes as determined by the surety companies in their reasonable discretion. This information is held in strict confidence.

*

I acknowledge that I have read and agree to the above Terms of Service on the following date:

*

Medicare DMEPOS Bond Application

Contact Information

Applicant Information

Please indicate if any of the following items apply to the business or any of the owners involved.

Personal Information