Service Insurance Co Site Improvement & Subdivsion Bond Application

Site Improvement & Subdivision Bond Application

Allow approximately 10 minutes to complete this form
Each owner/ additional owner & spouse needs to complete this online application form separately for data security purposes
Are you working with an insurance agency for this bond?*

YesNo
Name of insurance agency
Name of insurance agent

First NameLast Name
Agent's Email
example@example.com

Developer/ Applicant's Information
Name of Development Project*
Corporate name as it appears on formation document
Name of Owner (Primary Applicant)*

First NameLast Name
Contact email*
example@example.com
Contact phone #*
Format: (000) 000-0000.
Applicant's Social Security #*
Address of business*

Street Address

Street Address Line 2

CityState

Zip Code
Owner Applicant Title*
Title Other*
Primary Applicant's Ownership %*
Project Information
State where the project is located*
Service Insurance is licensed in 21 states. If your state is not listed, please email GetMyBondNow@servicebonding.com
Street Address/Location of Development Project *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Obligee Location (city, municipality, township or the entity requiring bond) *
Name of Obligee Location
What is the required bond amount?*
Estimated Cost of Improvements?*
Cost of Land (if applicable)
Cash Paid for Property (if applicable)
Date Purchased

MonthDayYear
Date
Number of homes/ units:
Estimated cost of each:
Estimated sale price of each:
Name of Contractor Providing the Site Improvements (if applicable)
Name of Contractor
Does the developer have similar previous experience?*

YesNo
Project Name
Bonding Company
Number of Homes Sold/ Status of Work
Financing Information
Is there a Mortgage?

YesNo
Mortgage Amount?
Name of Mortgage Holder?
Does the developer have an open line of credit with any financial institution?

YesNo
Name of Financial Institution
Credit Limit?
Credit Available?
Primary & Any Additional Owner's Information
Primary Owner Home address is same as business address

YesNo
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Prior year personal income*
Married Yes/No*

YesNo
Name of Spouse*

First NameLast Name
Spouse Email*
example@example.com
Spouse Social Security #*
Spouse of Owner
Name of Additional Owner 1*

First NameLast Name
Address Additional Owner 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Owner 1 Email*
example@example.com
Additional Owner 1 Ownership %*
Additional Owner 1 Prior year personal income*
Additional Owner 1 Social Security #*
Additional Owner 1
Married Yes/No*

YesNo
Name of Additional Owner 1 Spouse*

First NameLast Name
Additional Owner 1 Spouse Email*
example@example.com
Spouse Additional Owner 1 Social Security #*
Spouse Additional Owner 1
Are there any Other Owners?*

YesNo
Name of Additional Owner 2*

First NameLast Name
Address Additional Owner 2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Owner 2 Email*
example@example.com
Additional Owner 2 Ownership %*
Additional Owner 2 Prior year personal income*
Additional Owner 2 Social Security #*
Additional Owner 2
Married Yes/No*

YesNo
Name of Additional Owner 2 Spouse*

First NameLast Name
Additional Owner 2 Spouse Email*
example@example.com
Spouse Additional Owner 2 Social Security #*
Spouse Additional Owner 2

Has the applicant(s) or their spouse(s), or the business (check YES or NO)*

Rows	YES	NO
Ever filed for bankruptcy?
Any criminal convictions?
Any prior or pending lawsuits, judgments or liens (including taxes)
Have you applied for bonding or received any surety bonds within the past twelve (12) months?

If you answered "YES" to any above, please provide details:*
Upload any special bond forms or supporting documents relating to bond needed:

For potentially higher bond limits, please include the last two months business and personal bank statements and the most recently filed business and personal tax returns.
Cancelof
I agree to the following indemnity agreement and fraud statement*

I Agree
INDEMNIFICATION AGREEMENT — READ CAREFULLY BEFORE SIGNING BELOW

All Applicants/Signatories to this Agreement (collectively, “Indemnitors”) agree to indemnify The Service Insurance Company (hereinafter, “Company”) from any loss, liability, or damages, financial or otherwise, in connection with any bond(s) or undertaking(s)(collectively, “bond(s) executed by Company at any time on behalf of any person or entity applying for such bond(s). Indemnitors certify that all information provided to the Company is true, and that Company is relying on this information to issue and/or renew a bond(s). Indemnitors authorize the Company or its agents to investigate our credit with any institution or entity, now and at any time in the future. In consideration of Company issuing and/or renewing any bond(s), Indemnitors agree:
I Agree*

1. To pay Company: a. all premium due on each bond(s), and all renewal premium due on each annual anniversary on every bond issued by the Company, until the Company has received satisfactory evidence that such bond(s) have been discharged and the Company’s liability has terminated. Premium is fully earned and not refundable in the first year of coverage; and b. all monies demanded by the Company to cover the costs of any investigation, claim adjustment expense ,liability, claim, lawsuit, legal fees or judgment incurred by the Company as a result of executing any such bond(s); and c. a cash deposit upon demand by the Company to establish a reserve to defend against potential claims if the Company deems necessary. The Company may use this sum to pay such claims or hold as collateral against loss or costs on the bond(s) at its discretion.
I Agree*

2.To individually, jointly and severally, agree to hold Company harmless and indemnify Company from any and all liability, damages, losses, costs and expenses of any kind, including attorney’s fees, which may be incurred arising out of the execution, enforcement procurement of release in connection with such bond(s).
I Agree*

The Company has the exclusive right to defend, settle, pay or appeal any claim made on any bond(s) executed by the Company on behalf of Indemnitors. An itemized statement of loss and expense incurred by the Company shall be sufficient evidence of the extent of Indemnitors’ liability to the Company.
I Agree*

4. The Company may decline to issue any bond(s) applied for and may cancel, amend, or terminate same without incurring liability to Indemnitors. The obligations of Indemnitors are joint and several. The invalidity or unenforceability of any provision herein shall in no way affect the validity or enforceability of any other provision. This Agreement may be executed by electronic signature, which shall be given the same legal effect, validity and enforceability as a handwritten or manual signature to the fullest extent permitted by applicable law, including the Federal Electronic Signature in Global and National Commerce Ace, the New York State Electronic Signatures an Records Act and any other applicable law, including, without limitation, any state law based on the Uniform Electronic Transactions Act.
I Agree*

5. FRAUD STATEMENT: 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.
Each Owner Needs to Complete a Separate Application
Name of Development Project*
Print Name
Personal & Business indemnitor signature*
Signer's Name*

First NameLast Name
Please Verify That You are Human*
Each owner needs to complete this online application form separately for data security purposes
New Jersey Office
80 Main Street, Suite 330
West Orange, NJ 07052
N.J. Phone: (973) 731-7650
N.J. Fax: (973) 731-7889

Long Island Office
35 Pinelawn Road, Suite 111-E
Melville, NY 11747
N.Y. Phone: (631) 343-4305

The Service Insurance Company, Inc.
(in CT, GA, KY, MA, MD, MS, NH, NJ, NY, PA, RI, TN & WV)

Service Guarantee and Surety Company
(in AL, FL and VA by: The Service Insurance Company, Inc.)

The Service Insurance Company, Inc.
d/b/a Service Guarantee and Surety Company
(in DE, NC, SC and the District of Columbia)

GetMyBondNow@servicebonding.com
Should be Empty:

Site Improvement & Subdivision Bond Application

Developer/ Applicant's Information

Project Information

Financing Information

Primary & Any Additional Owner's Information

INDEMNIFICATION AGREEMENT — READ CAREFULLY BEFORE SIGNING BELOW

Each Owner Needs to Complete a Separate Application