Name*

Home Address*

Length of time at that address*

Previous home addresses for past 5 years

Please list all and separate with semi-colon

Email Address*

Bail Bond/Ins. Lic #

Social security number*

Driver's license number*

Home phone

Mobile phone

Business phone

Fax number

Pager/other

Are you presently in the bail bond business?*
YesNo

If yes please complete the form below

How long have you been in the bail bond business?*

Current Surety Company

Agency name or affiliation

Business Address

Do you own the company?
YesNo

If yes, is the agency a:
CorporationLLCPartnershipSole proprietorship

if no leave it blank

List below any companies or general agents with whom you have ever worked, and the applicable dates, or if you have been a Professional or Property Bondsman.

Do you currently have a Build Up Fund with another Company or General Agent?
YesNo

If yes, how much?

Can your present employer be contacted?
YesNo

How did you hear about Lexington National?

Why are you looking for a new surety?

What amount of annual bond liability do you currently write?

What amount of annual bond liability do you expect to write with Lexington National?

In what territory do you currently write?

Has any insurance company, general agent, or county/parish/jurisdiction terminated business with you in the past?*
YesNo

If yes, enter comments. If no leave it blank.

Has it ever been necessary for payment of forfeitures, estreatures, or judgments to be paid out of your BUF or by your Surety?*
YesNo

If yes, enter comments. If no leave it blank.

Are you indebted (other than accounts current) to any surety company, producer, or principal, or has any judgment ever been rendered against you for money received or owed to any surety company, producer, or principal?*
YesNo

If yes, enter comments. If no leave it blank.

Have you had any business or professional license suspended or revoked or are such proceedings pending against you?*
YesNo

If yes, enter comments. If no leave it blank.

Has any disciplinary action ever been taken against you by any public authority (including a law enforcement agency or the Dept. of Insurance)?*
YesNo

If yes, enter comments. If no leave it blank.

Have any Judgments, Suits, or Tax Liens been filed against you?*
YesNo

If yes, enter comments. If no leave it blank.

Have you ever filed for bankruptcy or been put in an involuntary bankruptcy or receivership?*
YesNo

If yes, enter comments. If no leave it blank.

Have you ever been arrested or charged with a crime?*
YesNo

If yes, enter comments. If no leave it blank.

Are you a lawyer, law enforcement officer, or jailer, or do you have any custody or control over prisoners?*
YesNo

If yes, enter comments. If no leave it blank.

Reference #1 Name*

Reference #1 Relationship*

Reference #1 Phone*

Reference #2 Name*

Reference #2 Relationship*

Reference #2 Phone*

Reference #3 Name*

Reference #3 Relationship*

Reference #3 Phone*

Please provide any pertinent information about your educational background, employment history, military service, and involvement in any civic or charitable organizations.

Cash*

Stocks/Bonds*

IRA/401k*

Receivables*

Do you own your home?
YesNo

If yes, complete the form below

Fair Market Value

Total Owed to Mortgage Company

Other Real Estate
YesNo

If yes, complete the form below

1# Other Real Estate Address

Fair Market Value

Total Owed to Mortgage Company

#2 Other Real Estate Address

Fair Market Value

Total Owed to Mortgage Company

#3 Other Real Estate Address

Fair Market Value

Total Owed to Mortgage Company

Do you have any outstanding taxes or other debt? (besides credit cards)
YesNo

If yes, complete the form below

Creditor

Amount

Creditor

Amount

Creditor

Amount

Applicant Signature*