LLC Employee Worker Bonds Additional information will be required prior to issuing the bond. For court and fidelity bond needs, please contact our office prior to completing the application. BOND INFORMATIONType of Bond (attach Bond Form)(Required)- select -Contractor LicenseMotor Vehicle DealerBMC – 84LLC Employee WorkerWage & WelfareUtility DepositLiquorLost TitleDMEPOSOtherCA app fee or license numberWhat is your MC/FF#Type of licenseIf the bond amount is over $50,000, we will need additional underwriting information to approve.Amount of Bond(Required)Effective Date MM slash DD slash YYYY Obligee Name (Who is Requiring the Bond?)(Required)Obligee Address: (full address) Expiration Date: (If other than one year) MM slash DD slash YYYY BUSINESS INFORMATIONCompany Name (As Appears on Bond)(Required)Business Phone #CA License or App Fee #Company Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County Business is Located InNature of Business--- Proprietorship Corporation Partnership LLC Date Formed MM slash DD slash YYYY # of Owners, Partners or Members(Required)Please enter a number greater than or equal to 0.Years of experience in the industry?Please enter a number greater than or equal to 0.Ever had their business license suspended, revoked or denied? Yes No PERSONAL INFORMATION <div class="repeater-field-header"> <div class="repeater-field-header-title">Person <span class="repeater-field-header-count">1</span></div> <div class="repeater-field-header-acctions"> <ul> <li><i class="repeater-icon icon-down-open repeater-field-header-acctions-toogle" aria-hidden="true"></i></li> <li><i class="repeater-icon icon-cancel-1 repeater-field-header-acctions-remove" aria-hidden="true"></i></li> </ul> </div> </div> All owners including spouses must complete "Personal Information" - Add more sheets if necessaryOwnership % ?(Required)Applicant Name(Required)US Citizen ? Yes No Social Security #(Required)Date of Birth MM slash DD slash YYYY Spouses NameUS Citizen? (Spouse) Yes No Social Security # (Spouse)Date of Birth MM slash DD slash YYYY Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Ever been convicted of a crime? Yes No Are you the Trustee, Trustor, or Beneficiary of any Trust? Yes No Ever Declared Bankruptcy? Yes No Pending or Prior IRS Liens? Yes No Any Lawsuits Pending against you? Yes No Ever declined for Bonding Previously? Yes No Home Ownership? Own Rent Are there any current or prior claims? If yes, please explain.(Required) Yes No CommentIs there a current bond in place? If yes, please explain reason for obtaining a new quote Yes No CommentHow did you hear about us?(Required)Upload Documents Drop files here or Select files Max. file size: 5 MB, Max. files: 5. If you are an insurance agent, please complete the followingAgency NameAgent NameAgent Email Agency Phone NumberIf you are not an insurance agent and completing this application for yourself, please include the following.NameEmail Address(Required) Phone Number The individual named above, who is the owner/officer/related party of the applicant for this bond/policy, requested that this application be submitted to the Company (Construction Capital, Inc./CCI Surety, Inc.) for the purpose of “Underwriting” (determination for acceptability; potential, actual or future pricing; and other related services) of this bond/policy. A copy of such request for “Underwriting” of the bond/policy requested by the above individual was provided to and is maintained by this agent/agency. Further, this agent/agency discussed with the owner/officer/related party named above concerning the use of his/her personal credit history to facilitate the “Underwriting” of the applicant and received consent to use his/her personal credit history for such Underwriting purpose. Vermont: If the owner/officer/related party of the applicant is a resident of the state of Vermont, the Agent shall obtain the written consent of such individual owner/officer/related party stating that: “The individual owner/officer/related party of the applicant understands and agrees that by submitting the application for the bond or insurance on behalf of the applicant that his/her personal credit history may be obtained and used to facilitate the underwriting process (determination of acceptability; potential, actual or future pricing; and other related services) of this application.” Also, the Agent agrees to retain copy of this written consent for the Surety.
