48 Hour License and Permit Bond Request
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Principal/Applicant Individual Corp Other
Type of License for Which You are Applying?

Name
Address     #        Street Name      St./Ave.
City/State/Zip
Social Security #
Phone
Fax
Email
Tax ID (if applicable)
Your Name, or Business Name
(as it appears on the license
or permit that is being bonded)

Amount
To Whom Bond is Payable
Address
City/State/Zip
Explain Purpose of Bond

1. Has the principal/applicant been in business at
least 3 years in same location?
No Yes
Explain:
2. Does the bond guarantee payment of taxes and/or fees?No Yes
Explain:
3. Has principal/applicant ever filed for bancruptcy?No Yes
Explain:
4. Does the principal/applicant have
(or pending) any suits or judgements?
No Yes
Explain:
5. Does the bond guarantee any type of
environmental/pollution exposure?
No Yes
Explain:

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*On bonds over $5,000 please continue by filling out this Financial Statement below.
******************************************************************
Applicant is Married Single Separated
If married the financial statement is: Completed Jointly Not Completed Jointly
Individual Co-Partnership Corporation
Statement of Assets and Liabilities as of:
Month Year

* ASSETS * LIABILITIES
Cash Due to Banks (unsecured)
Stocks, bonds, etc Credit Cards
Accounts Receivable Taxes
Notes Receivable Accounts Payable
Vehicles Notes Payable
Equipment Due on Inventory
Home Due on Real Estate
Real Estate Other Liabilities
IRA Total Liabilities
Other Assets Net Worth
TOTAL ASSETS TOTAL LIAB. and NET WORTH

* Additional information may be required to verify balances over $10,000.

SOURCES OF INCOME FOR YEAR ENDED OTHER LIABILITIES

Salary, bonuses & commissions $ Do you have any contingent liabilities? No Yes
If Yes, explain
Dividends $
Real Estate Income $
Other income 1 $ Endorser, co-maker of guarantor? $
Other income 2 $ On Leases or contracts? $
Other income 3 $ Legal Claims (Judgments, etc) $
Other income 4 $ Other special debt $
TOTAL $ Amount of contested tax liens $

Are any assets owned by a trust?
No Yes
If Yes, describe
Ever declared bankrupt?
No Yes
If Yes, explain
Do you have a will?
No Yes   If Yes,
Name the executor
Are you a defendant in any suits or legal action?
No Yes
If Yes, explain
Are you a partner or officer in any other venture?
No Yes
If Yes, describe
Are any assets pledged?
No Yes
If Yes, explain
Any other obligations, alimony, child support, etc?
No Yes
If Yes, explain
Income tax paid through Year
Name your personal bank


By submitting information through this site, I authorize you and/or the surety to contact the individuals and companies given as references or other sources to gather information on the credit, character and capacity of the individuals and the company.
Name: Title: Date:
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or application containing any false, incomplete, or misleading information is guilty of a felony per state statute.

Press the Submit button below or you can fax or email to:
fax (561) 997-7087 or email to: bonds@beacongroupinc.com. or call 1-800 545-9007 ext. 133
Richard S. Wurst, ARM, AAI - License D048332 (Office use only)

 



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