General Instruction For Court Forms (Page 4 of 8) in pdf

General Instruction For Court Forms Page 4

Agent/Broker Information

Name of Insurance Agent/Broker:

Name of Insurance Agency:

Agent/Broker/Agency Address:

City:

State:

Zip:

Phone No.:

Fax No.:

E-Mail Address:

SS# or FEIN for Payee:

Agent/Broker License #:

Are you paying fees to a subproducer? Yes

If Yes, complete supplemental application.

Note to Agent, Broker and/or Agency: Please submit a current copy of your Agent, Broker

and Agency License with Application.

Note: If the application is not completed in its entirety, it may cause delay in

issuing the bond.

Collateral is required on most court bonds, the preferred form of collateral is a Letter of Credit.

The amount of collateral required must be equal to the bond amount plus the additional fee as

stated below:

Bond Amount

Additional Fee added to collateral

Up to $50,000

An additional $1,000

$50,001 - $250,000

An additional $5,000

$250,001 - $500,000

An additional $10,000

$500,001 and up

An additional 5% of the bond penalty

FA004 – Application for Court Bonds Other than Probate – 4/2012

General Instruction For Court Forms Page 4