Agent Application

Name*

First Last

Date of Birth*

Birthplace

City State / Province / Region Country

Driver's License No

Social Security Number*

Education Level

Home Address*

Street Address Address Line 2 City State ZIP Code

Length of Time at Current Residence

In years

Home Phone

Cell Phone

Past Employer 1

Position Held

Address

City State

Begin Date

End Date

Past Employer 2

Position Held

Address

City State

Begin Date

End Date

Spouse/ Cohabitant Name

First Last

Any business or employment you will maintain in addition to bonding?

If Yes, Company Name and/or type of business

Business Address

Street Address Address Line 2 City State ZIP Code

Position

Business Phone

Email

Financial Institution used for you Business Checking and Savings Accounts

City and State of Financial Institution

City State

Are you the Agency owner?

If No disregard the following information and process to the Bail License/Appointment Section

Agency License Number

State of Issuance

State

Effective Date

Expiration Date

Type of Entity Structure

All Owners Names

Federal Tax I.D. Number or Social Security Number if DBA

Name(s) for Build Up Fund Account

Do you have liability insurance?

Do you have Errors and Omissions? (required by some states)

Do you have a separate account for Cash collaterals?

If so, please list bank, authorized signers, account title and number, or General Agent's name you send to

Current Bail License

If No Please disregard this section and continue to Regulatory Information

Bail License Number

State of Issurance

State

Effective Date

Expiration Date

Copy of Bail License

Please send a copy now and after each renewal. Please keep current with state law about change of address, license renewal, and continuing education. Your license must be current to maintain your Appointment and continue writing bail bonds.

Do you have an Appointment with an insurance company?

Do you have a Civil Bond (required by some states)?

Do you have a "No Compete Contract" in force?

May we contact previous Company or GA for a reference?

Have you provided them notice you will be leaving

Have you accounted for all powers of attorney?

Current and Previous Appointments:

Please list all current and Previous appointment information. Insurance Company Name, Start Date and End date, General Agent (if applicable), Current Open Liability, Current Build Up Fund Balance

If Bail Experienced, please list an average of your: Yearly bonds written

Total amount of bonds written

Number of Yearly Forfeitures

Total amount of Yearly Forfeitures

Are you currently making payments to a court or insurance company, for past forfeitures, or do you have forfeitures pending in the future?

If Yes, Please list Court, Defendant Name, Case No., Past or Pending, Forfeiture Amount, Balance, and Due Date

Regulatory Information

These questions are being asked because state and federal law and/or insurance regulations require and hold insurance companies responsible for the thorough investigation of their Appointees.

Have you ever been convicted of a Felony, or currently have a case pending against you?*

Have you ever been convicted, or currently have a case pending for a Misdemeanor involving dishonesty or improper moral conduct?*

Has a Department of Insurance ever refused, suspended, assessed a fine against, or terminated a License for you or your Agency?*

Has a Court or Sheriff ever refused, suspended or terminated writing privileges for misconduct, or because of an unpaid forfeiture for you or your agency?*

Have you or your agency ever had a Bail Contract or relationship terminated for failure to remit premiums, improper collateral handling or illegal activity?*

Are you now involved, or have you ever been found liable in any lawsuit or official proceeding involving allegations of misrepresentation, fraud or misappropriation of funds?*

Are you an employee, shareholder, corporate officer or affiliated in any way with a bank, credit union, savings & loan, or other financial institution?*

Are you currently under a Court Order to pay Child Support?*

If so, are your Child Support payments current?*

Are your federal, state or local business or personal taxes delinquent now, or have they ever been delinquent?*

Have you ever filed Bankruptcy, or are you currently involved in filing Bankruptcy?*

IF ANY QUESTIONS ABOVE ARE ANSWERED "YES" PLEASE ATTACH COMPLETE OFFICIAL DOCUMENTATION, SHOWING STATUS IF OPEN AND FINAL DISPOSITION, IF CLOSED.

APPLICANT CERTIFICATION AND AUTHORIZATION TO RELEASE INFORMATION:*

I am providing this information for the specific purpose of applying for appointment as a Bail Agent authorized to post Surety Bail Bonds, in the Courts of my licensed state(s), on behalf of Universal Fire and Casualty Insurance Company. I hereby certify that I am making application to be insurance licensed, or that I am currently licensed for this line of business and that license is compliant and in good standing with all Department of Insurance licensing rules and regulations. I further certify that all information submitted in this application and attachments is true and complete. Should I be appointed, I understand that it is my obligation to keep this information accurate and up-to-date, with Universal Fire & Casualty Insurance Company, and its affiliates. This includes any notification I receive directly from a federal, state or court official concerning the censure, suspension or revocation of my bail license and/or writing privileges. I understand that I am also obligated to make immediate and full disclosure concerning any criminal or misdemeanor charges that should be brought against me, during the course of my company appointment. I understand that investigative inquiries can be conducted now or anytime during the tenure of this appointment. I acknowledge my right to make a reasonable written request to Universal Fire and Casualty Insurance Company to obtain information on the nature and scope of such an investigation. I hereby authorize Universal Fire and Casualty Insurance Company and its affiliates to obtain information from any and all relevant sources with regard to my financial and fiduciary responsibilities (including any credit reporting agency), past and present employment, business practices, license and appointment histories, insurance transactions, real estate and property holdings, criminal and judicial records, private business records including medical reports and any other information that may reflect upon my reliability, character, work habits, ethics and ability to effectively represent Universal Fire and Casualty Insurance Company and its affiliates. I authorize Universal Fire and Casualty Insurance Company and its representatives to share this information with other individuals or companies who are participating in my appointment process or tenure, or future appointment in the insurance industry. I hereby authorize any person or entity requested to furnish the above information to Universal Fire and Casualty Insurance Company and its affiliated representatives, upon the presentation of this document in its original form, in a photocopy or facsimile version.

APPLICATION FOR BAIL AGENT APPOINTMENT

Regulatory Information