Form Sen-Co-33 - Application For Bail

APPLICATION FOR BAIL

Amt. of Bail $_________________

Total Charges $

Premium Chg $

Received

$

th

Seneca Insurance Co., 160 Water St, 16

Fl, New York, NY 10038 (212) 344-3000

Date of Bond:_____________________________________

Bond Power No.

Balance

$

Producer Name, Address, Phone Number and License Number

Defendant’s Booking Name ________________________________________________________ True Name

Street Address__________________________________________ Apt_______________ City & State_______________________ How Long

Home Phone ______________________________ Cell Phone________________________________ D.O.B_____________ Sex____ Race

Height

Weight

Hair

Eyes _______________ Glasses _______ Moustache

I.D.Marks

Birthplace_________________________S.S.#_____________________D.L.#

Date of Arrest _____________ Where Held_______________ Charges

Case #__________________________________ Booking#_____________________________ Date to Appear_________________

Time

Court________________________ Jud. Dist.________________________ Div. or Dept_______________________ County

Former Address___________________________________Apt#_________ City and State_________________________________How Long

Employer________________________________________ Address________________________________ Phone

Occupation_________________________ Mo. Income_______________ Supervisor_____________ How Long

Previous Arrest Charge________________ Court_________________________ County_______________ Dates Arrested

Disposition_______________________________ Previous Bail_______________ By Whom_________________ Amount of Bail $

On Probation?_____________ Where_______________________________ Probation Officer

Vehicle Make______________________ Model___________________ Year_________ Color___________________ License #

Real Estate Description________________________________________________________ Value_______________

Mortgage Amount

Spouse_____________________________ Address________________________________ City & State_______________ Home Phone

Spouse’s Cell Phone________________________ D.O.B_________________________ S.S.# ___________________________

Spouse’s Employer____________________ Address _________________________________ City & State______________ Phone

Spouse’s Vehicle Make_________________________ Model_________________ Year _________Color____________ License #

Children Names & Ages

REFERENCES:

Name

Address

Phone No.

Cell Phone

Relationship

1.

Father

2.

Mother

3.

Sis/Broth

4.

Friend

INDEMNITOR NAME: _______________________________________________ Home Phone _______________________ Cell Phone

Address ___________________________________________ City,State,Zip

Social Security #_________________________D.L.#_________________________D.O.B.________________ Relation to Defendant

Employer____________________________ Address_____________________________________________________ Phone

Occupation

How Long

Spouse ______________________________Spouse’s Employer____________________________ Address

Occupation

How Long

Vehicle Make ________________________ Model _______________ Year ______________ Color _______ License #

Collateral Type ____________________________________________________________________ Amount Taken ____________________________

INDEMNITOR NAME: ______________________________________________

Home Phone _______________________ Cell Phone

Address ___________________________________________ City,State,Zip

Social Security #__________________________ D.L.#_________________________D.O.B.______________ Relation to Defendant

Employer_________________________________ Address________________________________________________ Phone

Occupation

How Long

Spouse _______________________________Spouse’s Employer____________________________ Address

Occupation _______________________________________________________________________ How Long _______________________________

Vehicle Make _______________________ Model _______________ Year ______________ Color _______ License #

Collateral Type ____________________________________________________________________ Amount Taken ____________________________

It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to

defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company

who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud

the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within

the department of regulatory agencies. § 10-1-128(6)(a) C.R.S.

In order to receive a return of your collateral from your producer you must deliver a copy of the court order resulting in a release of the bond by the court to the producer

or the surety company.

I certify that the above is true and correct. I further understand that this is an application for a type of credit and authorize a review of my credit history via credit reporting agency checks.

Indemnitor’s Signature

Date

Indemnitor’s Signature

Date

Producer’s Signature

Date

Defendant’s Signature

Date

SEN-CO-33-Rev 2013