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Illinois Department of Insurance

320 West Washington Street

Springfield, IL 62767-0001

Insurance Producer/Business Entity Bond

Co. Code # ________________

Bond # ___________________

KNOW ALL MEN BY THESE PRESENTS, THAT I/we ___________________________________________

residing at ____________________________________________________________________________________

__________________________________________________________, an Insurance Producer/Business Entity,

as principal and ___________________________________________________________________ a company

duly authorized to transact surety business in the State of Illinois, as Surety, are held and firmly bound unto the

People of the State of Illinois and payable to any party injured under the terms and conditions of this bond, in the full

and penal sum of ___________________________ ($

) dollars lawful money of the United States

of America, for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators,

successors and assigns, jointly and severally, firmly by these presents.

THE CONDITION OF THIS OBLIGATION IS SUCH that the above bonded Principal is now or is about to

become licensed to engage or continue in the business of an Insurance Producer/Business Entity, as provided by

the Illinois Insurance Code, as amended.

NOW, THEREFORE, if the said Principal shall, while this bond is in force and effect make a full accounting and

due payment to the person or company entitled thereto of funds coming into his possession as an incident to

insurance transactions, and shall comply with all the provisions of Section 500-30 of the Illinois Insurance Code, as

amended, then this obligation shall be null and void; otherwise to remain in full force and effect.

PROVIDED, HOWEVER, that this bond shall be continuous in form and may be terminated by the Surety, upon

its giving thirty (30) days notice to the principal of its intention of termination.

IN WITNESS WHEREOF, the said principal has hereunto set his hand and seal, and the said surety has

caused these presents to be signed by its duly authorized officers and its corporate seal to be hereto affixed this

_________ day of _____________________, 20______.

*(Signature of Principal)--Social Security Number

(Bonding Company)

(Social Security Number/FEIN Number)

(Signature of Officer)

(Signature of Attorney-in-Fact)

Important Notice: Under the Illinois Revised Statutes' insurance laws, disclosure of this information is voluntary; however, failure to comply

may result in this form not being processed. This form has been approved by the Forms Management Center.

IL446-0152B Rev. 5/09

Insurance Producer/Business Entity Bond

Form Il446-0152b - Insurance Producer/business Entity Bond - Illinois Department Of Insurance