Bail Bond Application

Part I - Business

Application Date*

Supervising Agent*

Applicant Name*

First Last

Social Security Number*

Date of Birth*

Business or Trade Name (if any)

Is the Business a:*

Corporation
Partnership
Sole Propietorship

Fed Tax ID#*

Bail License #*

Business Address

Address - Business*

Street Address Address Line 2 City State ZIP Code

How long at this address?

Years*

Months*

Business Phone*

Fax

Cell Phone

Other Phone

Email*

Home Address

Address - Home*

Street Address Address Line 2 City State ZIP Code

How long at this address?

Years*

Months*

Are you a citizen of the United States?*

Yes
No

If married, what is the full name of your spouse?

A producer is an independent contractor not an employee.

Part II - Background Information

How Long in the Business?*

Estimated Annual Liability $*

List below the surety companies you have previously represented, whether direct or through a general agent, your reason for leaving, and estimated open liability.*

Do you have a non-compete agreement with your previous surety? If yes, please provide a copy of it with this completed worksheet.*

Yes
No

Do you have a confidential agreement with your previous surety? If yes, please provide a copy of it with this completed worksheet.*

Yes
No

Do you currently have a Build Up Fund with another Surety or General Agent?*

Yes
No

If YES, list amount and company

Amount

Company

Has it ever been necessary for payment of forfeitures, estreatures or judgments to be paid out of your BUF or by your Surety?*

Yes
No

Are you indebted to any surety company, producer or principal? Has any judgment ever been rendered against you for money owed to any surety company, producer or principal?*

Yes
No

If YES, provide full explanation below.

Have you previously held an Insurance or Bail license in any other state?*

Yes
No

If YES, what state and was it revoked?

Has disciplinary action ever been taken against you by law enforcement or Department of Insurance?*

Yes
No

If YES, provide full explanation below.

Have you ever been charged or convicted of, pleaded guilty or no contest to any misdemeanor or felony or currently have pending charges filed against you?*

Yes
No

If YES, provide full explaination below.

Part III - References

Please submit three letters of reference or names and phone numbers of three personal references. References should not include relatives, supervising agent and/or staff in office.

Name*

Phone*

Name*

Phone*

Name*

Phone*

Part IV - General Information

If less than five years in the bail bond business, list prior employment and length of time. Include military service and involvement in any civic or charitable organizations.

Can your present employer be contacted?*

Yes
No

List the counties and courts in which you will be writing the majority of your bonds.*

Part V - Certification

I hereby certify that all entries on both pages and attachments are true and complete, and I agree and understand that any falsification of information herein, regardless of the time of discovery, may cause forfeiture on my part to any contract of Bail USA, Inc. it’s Indemnitors, General Agent’s and Re-Insurers, all of which shall hereafter be termed the Company.

This information is to be used for possible contractual agreement between myself, and the Company; It will not be made available for public inspection.

I agree to conduct myself in a legal and professional manner while acting as an independent contractor at all times. Should my conduct or that of my employees, contractors, or principals result in a civil or criminal complaint I release Bail USA, Inc. from ANY and ALL liability as a result of my actions.

I hereby authorize any person, agency, partnerships or corporation having any information concerning my character, financial reputation and/or criminal background to release such information to the Company. I also release such person, agency, partnerships or corporation from any liability which may be incurred in releasing this information to the Company, including liability under any Federal Laws.

Signature PIN - Please enter a combination of 6 letters and numbers. This will serve as your electronic signature.

PIN*