Fillable Bankers Indemnity Agreement printable pdf download

NDEMNITY

GREEMENT

INS UR ANCE GROUP

RELATIONSHIP

TRUE NAME

DOB

ADDRESS

APT. #

CITY

STATE

ZIPCODE

Buying

Renting

HOME PHONE

WORK PHONE

CELL PHONE

OCCUPATION

EMPLOYED BY

HOW LONG?

EMPLOYER'S ADDRESS

CITY

STATE

ZIP CODE

SS#

DRIVERS'S LICENSE #

NAME OF SPOUSE

DRIVERS'S LICENSE #

S.S.#

DOB

SPOUSE'S EMPLOYER

HOW LONG?

ADDRESS

CITY

WORK #

REFERENCE

ADDRESS

PHONE

WHEREAS, Bankers Insurance Company, a Florida Corporation (hereinafter called the SURETY) at the request of the undersigned, and upon the security

hereof, has, or is about to become SURETY on an appearance bond for

in the sum of

Dollars by its certain bond or undertaking, a copy of which is attached hereto and made a part hereof:

NOW THEREFORE, in consideration of the premises and the sum of one dollar in hand paid, receipt whereof by each of us is hereby acknowledged, the

undersigned do/does hereby undertake, agree and bind themselves, their representatives, successors and assigns, as follows:

1. That the undersigned will have the aforesaid

forthcoming before

the court named in said bond, attached hereto, at the time therein fixed, and from day to day and term to term thereafter, as may be ordered by the said court.

2. That the undersigned will at all times indemnity and save SURETY or its Agent, harmless from and against every and all claims, demands, liability, cost, charge,

counsel fee, expense, suit order, judgment or adjudication whatsoever which the said SURETY or its Agent shall or may for any cause at any time sustain or incur

by reason or in consequence of the said SURETY having executed said bond or undertaking, will upon demand, place the said SURETY or its Agent in funds to

meet every claim, demand, liability, cost, charge, counsel fee, expense, suit order, judgment, or adjudication against it, by reason of such Suretyship, and before it

or its Agent shall be required to pay the same.

3. The condition of said Indemnity Agreement provides that as long as there is any liability or loss of any nature whatsoever to the SURETY upon the bond referred

to herein, the undersigned will not make any transfer, or any attempted transfer of any of the property, real or personal given as security or which the undersigned

may subsequently acquire or any interest therein, and it is further agreed that the SURETY or its Agent shall have a lien upon all property of the undersigned for

any sums due it for which it has become, or may become, liable by reason of its having executed the bond referred to herein.

4. The voucher or any other evidence of any payment made by the said SURETY or its Agent, by reason of such Suretyship, shall be conclusive evidence of such

payment against the undersigned and the undersigned's estate both as to the property thereof and as to the extent of the liability thereof to the said SURETY.

5. That the said SURETY or its Agent, may withdraw from its Suretyship upon said bond or undertaking at any time that it may see fit, as provided by law.

6. That the Agreement shall not be returned by the said SURETY or its Agent, at the time it shall be satisfied of the termination of its liability under said bond or

obligation, but shall be retained.

7. That the failure of any of the undersigned to comply with the provisions of this Indemnity Agreement shall be binding upon the others.

8. If any provision or provisions of this instrument be void or unenforceable under the laws of any place governing its construction or enforcement, this instrument

shall be void and vitiated thereby but shall be construed and endorsed with the same effect as though such provision or provisions were omitted.

9. Indemnitor(s), hereby authorize any person, agency, partnership, or corporation having any information concerning my character and financial reputation to

release such information to Bankers Insurance Company, its assigns and/or duly authorized representatives. I hereby release such person, agency, partnership, or

corporation from liability which may be incurred in releasing this information to Bankers Insurance Company, its assigns and/or duly authorized representatives.

10. I hereby waive any and all rights I may have under Title 28 Privacy Act Freedom of Information Act, Title 6, Fair Credit Reporting Act, and any such local or

State law. I Consent to and authorize Bankers Insurance Company, and/or its Agent, to obtain any and all private or Public information and/or records concerning

me from any party or agency, private or government (local, State, Federal), including, but not limited to, Social Security Records, criminal records, civil records,

driving records, telephone records, medical records, school records, workers' compensation records, employment records. I authorize without reservation, any

party or agency, private or government (local, State, Federal), contacted by Bankers Insurance Company, and/or its Agent, to furnish any and all private and public

information and records in their possession concerning me to Bankers Insurance Company, and/or its Agent.

For good and valuable consideration, the undersigned principal agrees to indemnify and hold harmless the surety company or its agent for all losses not otherwise

prohibited by law or by rules of the Department of Insurance.

IN WITNESS WHEREOF, the undersigned have duly executed these presents this

day of

(L.S.)

Witness

Indemnitor

(L.S.)

Witness

Indemnitor

BIC9920080505