Medicare DMEPOS Bond Application

*Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerning any material fact whereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties.

Contact Information

*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

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

Personal Information

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

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

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.