You, the undersigned Defendant (“Defendant” or “you”), hereby represent and warrant that the following declarations made and answers given are true, complete, and correct and are made for the purpose of inducing Lexington National Insurance Corporation (“Surety”) to issue or cause to be issued, bail bond(s) or undertaking(s) for you (singularly or collectively the “Bond”), using power of attorney number(s) (if known) in the total amount of in the Court of .
NameFirst* Middle Last*AKAHome Phone # Cell Phone # Work Phone # Email Email Facebook Username Other Social Media Current Home Address Street Address City Postal/Zip Code How Long Number Rent or Own Landlord/Mortgage Holder Former Home Address Street Address City Postal/Zip Code How Long Resided in Current City State Prior City/State Lived in How Long
Date of Birth City and State Born Male Female Race Social Security #Driver’s License # Issuing State Height Weight Eye Color Complexion Hair Color Glasses Yes No Scars, Marks, Tattoos U.S. Citizen Yes No How Long in the U.S. Nationality Alien # Any Medical Conditions/Disabilities
All occupations for the past 5 years Current Employer Name How Long Phone #Position Address Supervisor’s Name Most Recent Former Employer NameHow Long Phone # Position Address Supervisor’s Name Next Most Recent Former Employer Name How Long Phone # Position Address Supervisor’s Name Union Local # Military Service: Branch Active Yes No Discharge Date
Married Divorced Separated Widowed Single Cohab How long married/together Spouse/girl/boyfriend’s NameblankSocial Security # Address (if different) Email Home Phone # (if different) Cell Phone Work Phone Employer Position How Long Supervisor’s Name Former Spouse’s Name Child’s Name ---- Date of Birth ---- School/Employer ---- Other Parent’s Name
Describe Auto: Year Make # Model Color Plate State Where Financed Amount Owed Insurance Company Name Ins. Agent’s Name Ins. Agent’s Phone
Date of Arrest Booking Name (if different) blank Arresting Agency Jail Location Booking Charges Previous Arrests: Charges ----- Date ------- Where Pending Charges in Other Counties Are you on parole/probation Yes No Parole/probation officer name and phone Are you now under any bond? Yes No Have you ever failed to appear in court? Yes No Bonded before by When
Name and Firm Phone #.
Father’s Name Address Home Phone: Cell Phone Email Employer Mother’s Name Address Home Phone Cell Phone Work Phone Email Employer Other Relative/Friend’s Name Relationship How long known: Address Employer Home Phone Cell Phone Work Phone Email Email Social Media: Other Relative/Friend’s Name Relationship How long known: Address Employer Home Phone # Cell Phone # Work Phone Email Email Social Media:
BAIL BOND APPLICATION AND AGREEMENTTERMS AND CONDITIONSIn consideration of Surety, through its producers, representatives or designees, issuing or causing to be issued the Bond, you agree to the following terms and conditions:1. The premium is fully earned upon your release from custody. The premium is not refundable except as stated below.2. Surety, as bail, shall have control and jurisdiction over you during the term for which the Bond is in effect and shall have the right to apprehend, arrest and surrender you to the proper officials at any time as provided by law. In the event your surrender is made prior to your failure to appear in court, and for reason other than as stated in Paragraph 3, then you may be entitled to a refund of the bond premium if required by applicable law (if any) as stated in an attached addendum. 3. Unless otherwise provided by applicable law (if any) as stated in an attached addendum, the following events shall constitute a breach of your obligations to the Surety, and the Surety shall have the right to immediately apprehend, arrest and surrender you, and youshall have no right to any refund of premium whatsoever: (a) you depart the jurisdiction of the court without the prior written consent of the court and the Surety; (b) you move from your current address without the prior written consent of the Surety or you fail to notify Surety of any material information; (c) you commit any act that constitutes reasonable evidence of your intention to cause a forfeiture of the Bond; (d) you are arrested and incarcerated for any other offense (other than a minor traffic violation); (e) you make any materially false statement in this application; (f) any Indemnitor for you makes any materially false statement in the Indemnitor Application andAgreement; (g) your bail is increased; (h) any Indemnitor requests that you be surrendered; (i) there is a material increase in the risk assumed by the Surety (as determined by the Surety in its sole and absolute discretion) including, by way of example but not limitation, any collateral or security given for the Bond depreciates in value or becomes impaired, or (j) Other Conditions: _____________________________________________________________________________. 4. You shall indemnify the Surety and keep the Surety indemnified and hold it harmless from and against any and all losses, demands, liabilities, fees, and expenses relating to, or arising out of, Surety’s issuance or procurement of the Bond including, but not limited to, the following: (a) the principal amount of any forfeiture of, or judgment on, the Bond, plus any related court costs, interest and legal fees incurred, (b) a fugitive recovery fee if there is a forfeiture of the Bond (which fee is typically ten percent of the amount of the Bond for an in-state recovery), plus any out of pocket expenses, (c) any and all extradition costs that may be incurred to apprehend and return you, and (d) if a collection action is required, reasonable and actual attorneys’ fees plus any other costs, expenses, and/or assessments that may be incurred as a result of any forfeiture of the Bond subject to applicable law (if any) as stated in an attached addendum. The voucher, check, or other evidence of any payment made by Surety or its producer, by reason of such suretyship shall be conclusive evidence of such payment in any lawsuit against you both as to the propriety of such payment and as to the extent of your liability to Surety for such payment. Further, you will, upon demand, place with Surety the requisite funds to meet any such claim, demand, liability, attorneys’ fees, expense, or judgment, whether that demand is made before or after Surety has paid or advanced such funds.5. To the maximum extent permitted by applicable law, you hereby waive any and all rights you may have under federal law (including, but not limited to, Title 28 Privacy Act-Freedom of Information Act, Title 6, Fair Credit Reporting Act) and any local or state the law relating to Surety’s obtaining, and you consent to and authorize Surety to obtain, any and all private or public information and/or records concerning you from any party or agency, private or governmental (local, state, federal), including, but not limited to, credit reports, Social Security Records, criminal records, civil records, driving records, tax records, telephone records, medical records, school records, worker compensation records, and employment records. You further authorize, without reservation, any party or agency, private or governmental (local, state, federal), contacted by Surety to furnish in accordance with applicable law any and all private and public information and records in their possession concerning you to the Surety and direct that a copy of this document shall serve as evidence of said authorization. You irrevocably grant to Surety and its designees the right to enter your residence, or any other property that you own or occupy, without notice, at any time, for the purpose of locating, arresting, and returning you to custody, and subject to applicable law, you waive any and all causes of action in connection therewith including, without limitation, torts of trespass and false imprisonment. 6. You agree that Surety may attach a location tracking device on any vehicle owned or driven by you, at any time, without notice, and monitor the location of the vehicle through any available technology. You further agree that Surety may use location technologies to locate your wireless device at any time during the period of your bail and any applicable remission period, and the Bond is conditioned upon your full compliance with the following terms and conditions: (a) Surety, at its discretion, will use network-based location technologies to find you; (b) this is the only notice you will receive for the collection of your location information; (c) Surety will retain location data only while the Bond is in force and during any applicable remission period; (d) Surety will disclose location information only to the courts, as required by court order; (e) Surety and its licensed producers, designees and representatives will be the only persons with access to your location information; (f) YOU WILL NOT HAVE THE OPTION TO OPT-OUT OF LOCATION USE OR TRACKINGDURING THE BAIL PERIOD; and (g) all questions relating to location capability should be directed to Surety.7. If you leave the State, subject to applicable law, you waive any right to extradition proceedings and consent to the application of such force as may be necessary to return you to Surety and the court where the bond was posted.8. You hereby acknowledge and agree that neither the Surety nor any of its agents, producers, designers, or representatives has recommended or suggested any specific attorney or firm of attorneys to represent you in any capacity.9. In the event any provision herein shall be deemed to exceed any applicable state or federal law, then such provision shall automatically be deemed to have been revised to comply with such law so as to provide Surety with the maximum protection from any loss or liability. The invalidity or unenforceability of any provision herein (or portion thereof) shall in no way affect the validity or enforceability of any other provision (or portion thereof). The surety may assign any of its rights herein or arise out of any of the transactions contemplated hereby to any party including, without limitation, any of the Surety’s agents, producers, designees or representatives (“Assignee”) without notice to or consent from you. Subject to any limitations imposed upon Assignee by Surety, Assignee shall have the right to enforce in any action or proceeding any of Surety’s rights herein or arising out of any of the transactions contemplated hereby, and you shall not, and expressly waive any right to, assert the claim or defense that Assignee does not have the right to enforce such rights in any such action or proceeding.
ALABAMA RESIDENTSAny person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.ARKANSAS RESIDENTSAny person who knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.FLORIDA RESIDENTSAny person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.LOUISIANA, RHODE ISLAND & WEST VIRGINIA RESIDENTSIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.MAINE, TENNESSEE, VIRGINIA & WASHINGTON RESIDENTSIt is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of -defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.MARYLAND RESIDENTSAny person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly orwillfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.NEW JERSEY RESIDENTSAny person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.NEW MEXICO RESIDENTSANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.NEW YORK RESIDENTS - 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 information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OHIO RESIDENTSAny person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.OKLAHOMA RESIDENTSWARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.PENNSYLVANIA RESIDENTSAny 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 information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person criminal and civil penalties.
Signed, sealed, and delivered this day of ,20.
LEXINGTON NATIONAL INSURANCE CORPORATIONP.O. Box 6098Lutherville, Maryland 21094Phone: (888) 888-2245