Fill - Free fillable AND INDEMNITY AGREEMENT LOST INSTRUMENT BOND APPLICATION PDF form

Travelers Insurance Company of Canada

650 West Georgia Street

P.O. Box 11542, Suite 2500

Vancouver, British Columbia V6B 4N7

www.travelerscanada.ca

Page 1 of 4

LOST INSTRUMENT BOND APPLICATION

AND INDEMNITY AGREEMENT

Type of Bond: Open Penalty [ ] Fixed Penalty [ ]

Bond Amount: $___________________________ Name of Broker: __________________________________________________

Broker Knows Applicant Since:_______________________ Effective Date of Bond (dd/mm/yy): ________________________

COMPLETE BOX IF APPLICANT IS AN INDIVIDUAL

Name of Applicant:

Birthdate (dd/mm/yy):

Full Address:

E-mail Address:

Website Address:

Home Phone Number:

Business Phone Number:

COMPLETE BOX IF APPLICANT IS A CORPORATION/ LLC/ LLP

Name of Applicant:

Full Address: E-mail Address:

Website Address:

Organized Date (dd/mm/yy): Under Laws of: (Prov.)

(State) _______________________________

Name of President:

Name of Vice-President:

Name of Secretary:

Name of Treasurer:

Name(s) of Major Shareholders:

__________________________________________________ ( %) _________________________________________________ ( %)

1. Description of Lost Share Certificate(s) [ ] or Bond(s) [ ]

(hereinafter called “Original”, whether one or more);

Certificate/Bond

No.

Number of Shares/Face

Value of Certificate ($)

Issued By(hereinafter

referred to as the “Issuing

Corporation”)

Registered in the

Name of

Class of Shares (ie. Common,

Class A etc.)

2. Original has been lost, stolen, destroyed or misplaced under the following circumstances;

a) Where Kept b) Date of Loss (dd/mm/yy):

c) How Lost:

d) If stolen, provide details and copy of police report:

Page 2 of 4

3. Was Original endorsed for transfer? YES [ ] NO [ ]

If yes, describe form of endorsement and state whether signature was guaranteed.

4. If Applicant(s) is not the registered owner as describe under section 1 mentioned above, please state your representative or

fiduciary title/capacity (i.e. Estate Trustee, Guardian, Power of Attorney etc.). Provide supporting documentation of representative

capacity/title.

Name (identify title/capacity) Full Address & Telephone #

If Original should ever come into above named representative (under Section 4) hands, custody or power, representative will

immediately and without consideration surrender Original to the Issuing Corporation, its transfer agents, trustees or Travelers

Insurance Company of Canada (hereinafter referred to as the “Surety”) for cancellation.

Notice: When signing this application you are signing in your fiduciary capacity.

5. List all individual(s) having an interest in the Original and their nature of interest (i.e. heir/beneficiary, sole proprietor etc.)

Note: All listed individual(s) mentioned below must execute this application as Indemnitor

Full Name of Individual Full Address Relationship to Registered Shareholder Age

If Original should ever come into any of the above named individual(s) (under section 5) hands, custody or power, Individual(s) will

immediately and without consideration surrender Original to the Issuing Corporation, its transfer agents, trustees or the Surety for

cancellation.

Note: To avoid any disruption in providing a bond it is required that the above named interested individual(s) sign this

application as a Personal Indemnitor(s).

SPECIAL INSTRUCTIONS:

THE FOLLOWING DOCUMENTS MUST BE SUBMITTED WITH THE LOST INSTRUMENT BOND APPLICATION:

1. COPY OF TRANSFER AGENTS LETTER CONFIRMING A ‘STOP TRANSFER’ RESTRICTION PLACED AGAINST

REPORTED CERTIFICATE. LETTER MUST BE DATED WITHIN ONE YEAR FROM THE DATE OF THIS APPLICATION;

2. AFFIDAVIT/DECLARATION OF LOSS (EXECUTED IN TRIPLICATE);

3. PERSONAL WORTH STATEMENT (IF CURRENT VALUE OF CERTIFICATE EXCEEDS $50,000 CAD); AND

4. CERTIFICATE OF INDEPENDENT LEGAL ADVICE (IF CURRENT VALUE OF CERTIFICATE EXCEEDS $250,000 CAD)

NOTE: FORMS AVAILABLE AT WWW.TRAVELERSCANADA.CA

THE SURETY RESERVES THE RIGHT TO REQUEST ADDITIONAL INFORMATION.

Declaration: The undersigned hereby declare(s) that:

1. All the information provided herein is to the best of my/our knowledge true, complete and correct and understand it will be used by the

Travelers Insurance Company of Canada (hereinafter referred to as the “Surety”) to determine credit worthiness;

2. I/We consent(s) to the Surety making any enquiries it deems necessary to reach a decision on this application, and consent(s) to the

disclosure at any time of any credit information about me/us to any credit reporting agency or to any one with whom I/we have financial

relations; and

3. The Surety may complete any blanks left or correct any errors in completing any blanks herein, and such insertions or corrections shall be

prima facie correct.

Indemnity Agreement

THIS IS A BINDING AGREEMENT, PLEASE READ CAREFULLY

WHEREAS, the undersigned have applied to the Surety for one or more bonds to guarantee the obligations of any of the undersigned or other

forms of guarantee or obligation, (hereinafter referred to as “Bonds"; the word "Bonds" includes any alteration including, without limitation, any

increase or decrease in the bond amount, renewal, continuance, replacement or extension thereof).

Page 3 of 4

NOW THEREFORE, in consideration of the issuance of Bonds, whether past, present or future, by the Surety or procured by the Surety for or

on behalf of the undersigned or of the Surety refraining from cancelling such Bonds and of the sum of Two Dollars and other good and valuable

consideration paid by the Surety to each of the undersigned (the receipt and sufficiency of which are hereby acknowledged) the undersigned

hereby jointly and severally agree as follows:

1. The present agreement applies equally to Bonds issued on behalf of the undersigned or any employee or agent of the undersigned.

2. The undersigned undertake to indemnify the Surety in full for any loss or damages that it may suffer arising from the issue of one or several

Bonds, or arising from a decision of the Surety not to issue any Bond, or arising from any default by the undersigned under the present agreement.

The present undertaking includes, without limitation, the obligation of the undersigned to reimburse to the Surety all sums which it might be called

upon to pay:

a) as a result of a judgment, arbitration award or settlement;

b) as damages of any nature, including punitive and exemplary damages, as the case may be;

c) in respect of any claim, liability or loss;

d) as expenditure, costs or fees that it may incur, including the cost of internal or external adjusters and consultants;

e) in satisfaction of all legal fees and disbursements incurred by the Surety and legal fees and disbursements of claimants’ counsel;

f) as administration costs related to claims under Bonds and under this agreement

3. The undersigned undertake to pay to the Surety:

a) the initial premium for the issue of any Bond, in conformity with the Surety's tariff in force, or such other tariff as may be agreed

upon with the undersigned; and

b) thereafter, any additional or other premium, in conformity with the Surety's tariff in force or such other tariff as may be agreed

upon with the undersigned until such time as the Surety receives proof to its satisfaction, confirming its complete release from

all Bonds issued by it, and from the renewal or extension of such Bonds.

4. In order to permit the Surety to meet its obligations under the Bonds, the undersigned undertake to advance to the Surety upon demand, funds

or satisfactory guarantees sufficient to allow the Surety to perform any or all of its obligations under the Bonds, which could be subject to

indemnification under the terms of the present agreement, even before any payment has been made by the Surety to a third party. Without limiting

the generality of the foregoing, the undersigned undertake to advance funds or furnish guarantees, as soon as the Surety establishes or increases

a reserve with respect to a claim or a situation relating to any Bonds, up to the amount of such reserve which will be established by the Surety in its

sole discretion.

5. The undersigned acknowledge that the Surety will have the right, in its sole and entire discretion, to decide whether to pay, settle or contest

any claim under a Bond without any obligation to consult or advise the undersigned in advance of so doing. The undersigned acknowledge

their obligation to indemnify the Surety in virtue of the present agreement, upon presentation by the Surety of a release or a copy of a cheque

or any other proof of payment, which will be deemed to be complete proof of the amount paid and of the Surety's right to make such payment

as a result of the issue of the Bonds and, consequently, its right to demand reimbursement from the undersigned under the terms of the present

agreement.

6. The undersigned hereby renounce the benefits of division and discussion.

7. The present agreement shall extend to and be binding upon the heirs, executors, administrators, successors and assigns of the undersigned.

8. All of the terms and conditions of the present agreement are for the benefit of:

a) any predecessors or successors or assigns of the Surety, including as a result of mergers, name changes, acquisitions of portfolios, or

otherwise, and

b) any surety, joint or several, any re-insurance company and any other surety procured by the Surety upon the request of the

Principal

to issue a Bond or Bonds, whether or not such Bond or Bonds are issued by the Surety or whether or not the surety retains any

interest in any such Bond or Bonds.

9. The rights of the Surety by virtue of the present agreement are in addition to any rights which the Surety may have by law or otherwise.

10. The undersigned acknowledge and declare that:

a) before signing, they have obtained a copy of the present agreement and that they have had sufficient time to study its terms and

conditions; and

b) they have read and understood all of the provisions of the present agreement; and

c) they have been given the opportunity of asking for appropriate explanations or clarifications on the nature and extent of the provisions

of the present agreement; and

d) they have been given the opportunity to consult a legal or other advisor and, if they deemed it necessary, they have in fact consulted

such advisor.

11. Privacy Consent – Please note that without this consent, the Surety will be unable to consider your application.

The undersigned acknowledge that the evaluation of any application for products of the Surety will involve the collection, use and disclosure of

personal information, including the information contained in this application and other sources gathered through legal means.

Such collection, use and disclosure of personal information is for the purposes of underwriting bonds and policies, as well as bond or policy

management, which shall include conducting initial and on-going credit investigations, as well as Surety activities associated with all

extensions, renewals, substitutions and modifications of the bonds or policies, and claims administration. In the ordinary course of the Surety’s

business, personal information may be disclosed to reinsurers, legal advisors, credit bureaus, other financial institutions, regulatory bodies and

any third party deemed necessary by the Surety. In the event information about other individuals (e.g. family members, employees,

shareholders) is provided or collected from other sources, the undersigned represent and warrant that those persons have consented, to the

extent required by law, to the collection, use and disclosure of their personal information for the afore-mentioned purposes.

Page 4 of 4

The undersigned hereby agree and consent to the Surety’s:

a) collection and use of personal information concerning the undersigned for the purposes described above; and

b) disclosure of the undersigned’s personal information, for the purposes described above to such third parties as deemed necessary by

the Surety.

For further information, the Surety’s Privacy Policy is available for review online at www.travelerscanada.ca.

12. The present agreement shall be construed in accordance with the laws of the Province of British Columbia and the laws of Canada applicable

therein and shall be treated in all respects as a contract of the Province of British Columbia. Each of the parties hereto hereby irrevocably attorns to

the jurisdiction of the courts of the Province of British Columbia

IN WITNESS WHEREOF the undersigned have executed and sealed this Application and Indemnity Agreement this __________ day of

____________________________, 20______.

PERSONAL APPLICANT/INDEMNITOR SIGN HEREUNDER:

Signed at _________________________________________

__________________________________________________

Signature of Witness (Witness must be an unrelated third

party)

__________________________________________________

Printed Name of Witness

_________________________________________________

Address of Witness

__________________________________________________

Phone Number of Witness

_________________________________________________

Signature of Applicant/Indemnitor

_________________________________________________

Printed Name of Applicant/Indemnitor

_________________________________________________

Address of Applicant/Indemnitor

_________________________________________________

Phone Number of Applicant/Indemnitor

Signed at _________________________________________

__________________________________________________

Signature of Witness (Witness must be an unrelated third

party)

__________________________________________________

Printed Name of Witness

_________________________________________________

Address of Witness

__________________________________________________

Phone Number of Witness

_________________________________________________

Signature of Applicant/Indemnitor

_________________________________________________

Printed Name of Applicant/Indemnitor

_________________________________________________

Address of Applicant/Indemnitor

_________________________________________________

Phone Number of Applicant/Indemnitor

Note: If more personal indemnitors attach signature page.

CORPORATE APPLICANT/INDEMNITOR SIGN HEREUNDER AND AFFIX SEAL:

__________________________________________________

Name Of Corporation

By: ______________________________________________

__________________________________________________

Name

__________________________________________________

Title

I HAVE AUTHORITY TO BIND THE CORPORATION

By: ______________________________________________

_________________________________________________

Name

_________________________________________________

Title

I HAVE AUTHORITY TO BIND THE CORPORATION

Head Office Address:__________________________________________________________________________________________

Note: If more corporate indemnitors attach signature page.

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

AND INDEMNITY AGREEMENT LOST INSTRUMENT BOND APPLICATION

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank AND INDEMNITY AGREEMENT LOST INSTRUMENT BOND APPLICATION Form

Related forms

Fillable AND INDEMNITY AGREEMENT LOST INSTRUMENT BOND APPLICATION

Fill Online, Printable, Fillable, Blank AND INDEMNITY AGREEMENT LOST INSTRUMENT BOND APPLICATION Form

Related forms

First 20 documents completely FREE!