New York Automobile Broker Bond Application Page

CONTACT INFORMATION

Contact Name (If insurance agent, please include Agency Name) *

*

Applicant

Insurance Agent

Attorney

Other

Email *

Phone Number *

Fax Number

APPLICANT INFORMATION

Applicant or Business Name (Exactly as shown on License) *

*

Sole Ownership

Corporation

Partnership

LLC or LLP

Business Street Address *

City *

State *

Zip *

Do you have or need other bonds? *

Effective Date *

Bond Amount *

Obligee (Owner requiring the bond) *

Obligee Address *

Country

City

State

Zip code

Please indicate any ownership changes in the last 12 months:

Previous Surety? If yes, provide Surety below.

Reason for changing Surety

Has the business or any of the owners involved;

Had any lawsuits or judgments against them? *

Yes

No

Ever failed in business or declared Bankruptcy? *

Yes

No

Ever been convicted of a crime? *

Yes

No

Ever had their license suspended, revoked or denied? *

Yes

No

Ever been party to a surety bond claim? *

Yes

No

Ever had a bond declined or cancelled? *

Yes

No

PERSONAL INFORMATION — Owner #1

First Name *

Middle

Last Name *

Social Security Number *

*

Single

Married

Resident Street Address *

City *

State *

Zip *

# of years you have owned this business *

# of years experience *

% Ownership *

Phone Number *

Value of Primary Residence *

Balance of Mortgage *

PERSONAL INFORMATION — Owner #2 (if applicable)

First Name

Middle

Last Name

Social Security Number

Single

Married

Resident Street Address

City

State

Zip

# of years you have owned this business

# of years experience

% Ownership

Phone Number

Value of Primary Residence

Balance of Mortgage

PERSONAL INFORMATION — Owner #3 (if applicable)

First Name

Middle

Last Name

Social Security Number

Single

Married

Resident Street Address

City

State

Zip

# of years you have owned this business

# of years experience

% Ownership

Phone Number

Value of Primary Residence

Balance of Mortgage

PERSONAL INFORMATION — Owner #4 (if applicable)

First Name

Middle

Last Name

Social Security Number

Single

Married

Resident Street Address

City

State

Zip

# of years you have owned this business

# of years experience

% Ownership

Phone Number

Value of Primary Residence

Balance of Mortgage

PERSONAL INFORMATION — Owner #5 (if applicable)

First Name

Middle

Last Name

Social Security Number

Single

Married

Resident Street Address

City

State

Zip

# of years you have owned this business

# of years experience

% Ownership

Phone Number

Value of Primary Residence

Balance of Mortgage

Bond Form Upload

If the party requiring the bond gave you paperwork that included a specific bond form, please upload that form here. This will help streamline the process and get you the bond you need! Please Note: Multiple Files must all be uploaded at once.

TERMS OF SERVICE

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:

*