Cna Surety Contractor Application Form Page 2
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1
2
3Complete this page for Aggregate Programs in excess of $250,000, up
to $500,000.
Contractor's Company Name
File Number(s) Reference
Contractor's Company Address
City
State
Zip
FINANCIAL DATA
Please submit the following:
Business Financial Information for
Provide the company's latest CPA prepared fiscal year-end financial statement. If a
(C) Corporations, (S) Corporations,
CPA prepared financial statement is unavailable, provide the company's in-house
and LLCs:
prepared fiscal year-end financial statements along with the company's most recent
tax return.
or
Business Financial Information for
Provide the company's latest CPA prepared fiscal year-end financial statement. If a
Sole Proprietorships and
CPA prepared financial statement is unavailable, provide the company's in-house
Partnerships:
prepared fiscal year-end business financial statement and a copy of Schedule C from
the owners' most recent personal tax returns.
and
Personal Financial Statements
Provide a copy of each owner's personal financial statement. Include supporting bank
and marketable securities statements for verification purposes.
EXPERIENCE DATA
List the three largest contracts completed in the last five years:
Location
Contract
Year
Final
Owner or General
Kind of Work
(City/County, State)
Price
Completed
Gross Profit
List the two largest jobs you presently have underway, giving the following information:
Location
Contract
% of
Estimated
Date to be
Owner or General
Kind of Work
(City/County, State)
Price
Completion
Gross Profit
Completed
OPERATIONS DATA
Liability Insurance Company and Limits
Expiration Date
/
/
•
Type of trades you perform:
•
Territory in which you perform work (present and planned)
•
Trades subcontracted:
GENERAL DATA
Disputes, Financial Difficulties, Problems, Etc.
Company
Any officer, owner or partner
a. Failed in business or declared bankruptcy?
. . . . . . . . . . . . . . . . . . .
Yes
No
Yes
No
b. Failed to complete a job or been assessed with delay damages?
. . .
Yes
No
Yes
No
c. Been in claim with a Surety or denied bonding?
. . . . . . . . . . . . . . . .
Yes
No
Yes
No
d. Been involved in any lawsuits or disputes in the last 5 years?
. . . . .
Yes
No
Yes
No
e. Do you have any corporate or personal assets
held in trust or escrow accounts?
. . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
Yes
No
f. Are any business or personal assets restricted or pledged
for any purpose (i.e. collateral for a loan, etc.)?
. . . . . . . . . . . . . . . . Yes
No
Yes
No
g. Were you bonded in the past - By whom? . . . . . . . . . . . . . . . . . . . . .
Yes
No
Yes
No
Explain all "yes" answers fully below or attach explanation
AGENCY DATA
Agency Name
Agency Code
-
CNA Surety 101 South Phillips Avenue, P.O. Box 5077 Sioux Falls, SD 57117-5077 1-800-331-6053 / Fax 605-335-0357
CNA is a registered service mark, trade name and domain name of CNA Financial
Corporation. No part of this material, including the CNA Surety logo, may be
Page 2 of 3
reproduced without written permission from CNA Surety Corporation.
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Parent category: Business