P.O. Box 5077 Sioux Falls, SD 57117-5077 1-800-655-3551 / Fax 605-335-0357
http://CEM.cnasurety.com Email: uwservices@cnasurety.com
Application
Page 1 of 2
Form F6537-4-2019
Check and Complete
:
(check one only)
(
For private jobs or subcontracts please enclose a copy of the contract and bond form for projects over $150,000.)
,
(
For service type contracts provide a copy of the contract.)
,
Bid Bond
:
Bid date
Estimated total amount of bid: $
OR
Contract Price $
Any person who knowingly and with intent to defraud any insurance company or person files an application containing any materially false information or conceals,
for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime under applicable law. The
applicants and indemnitors certify the truth of all statements in the application and authorize the Company to verify this information and to obtain additional
information from any source including obtaining a credit report.
Performance & Payment Bond
Supply Bond
AGENCY DATA
Agency Name
Agency Code
-
Contract Date
(Date when contract is signed)
Has the applicant been in claim,
and/or
, denied bonding by another surety?
CONTRACTOR DATA
Type of Business:
Company Name
Company Address
City
Phone
Partnership LLCSole Proprietorship (S) Corporation (C) Corporation LLP
State
Zip
Type of Trade Date started in Business
E-Mail Address
Engineers Estimate: $
Bid Bond %, or flat amount
Status of Outstanding Bid or Performance Bonds:
Bond No. Bid Awarded: Yes No
Bond No. Bid Awarded: Yes No
No
Yes
Explain (if yes)
None
Stand Alone Maintenance
$
Subcontractor Performance & Payment Bond
Next two lowest bidders
Bond
Bid secured by: Check NegotiatedBond
AIA Form
CNA Form
Federal Contract #
State of Incorporation
(Send copy)
(Send copy)
State Form
Obligee Form
BOND FORM DATA
Name of Agent signing as Power of Attorney
CNA Surety may obtain a credit report about the Applicant including its Owner(s) and Owners' spouses in order to confirm the
information provided in this application and obtain information about Applicant's credit history. For new applicants, complete and sign
the General Indemnity Agreement.
BOND REQUEST DATA
Anticipated Start Date
Time for Completion Maintenance Period
Obligee
(Who is requiring the contractor get a bond?)
Job Legal Description (Project Name)
Obligee Address
*This application is not intended for use in connection with Design-Build Contracts, Subdivision or Site Improvement over $100,000,
Asbestos Abatement, Completion, Hazardous Materials, or Multi-Year Contracts where term of contract is over 5 years.
If no bond is needed at this time, but only prequalification for future bonding, check here
Job Physical Address
(Name here)
Northeast Agencies National Bond Program
(31-21688) An Allstate Commercial
Expanded Market Program
If you have any questions about the application,
please call 800-655-3551.
For Single Bonds or Aggregate Programs up to
$400,000, complete page 1.
For Aggregate Programs in excess of $400,000,
up to $800,000, complete page 1 and page 2.
State Zip
City
State Zip
City
OWNER DATA / INDEMNITORS
SS#SS#
DOB
DOB
Spouse NameSpouse Name
SS#SS# DOBDOB
City/State/ZipCity/State/Zip
AddressAddress
NameName
% of Business Ownership% of Business Ownership Married
NoYes
Married
NoYes
(Provide the information below on all owners; use additional sheet if necessary)
Scope of Work
$ $
No other bidders
Page 2 of 2
Complete this page for Aggregate Programs in excess of $400,000, up
to $800,000.
List the two largest jobs you presently have underway, giving the following information:
or
and
FINANCIAL DATA
Please submit the following:
Contractor's Company Name
Contractor's Company Address
File Number(s) Reference
State
City
Zip
AGENCY DATA
Agency Name
Agency Code
-
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
reproduced without written permission from CNA Surety.
P.O. Box 5077 Sioux Falls, SD 57117-5077 1-800-655-3551 / Fax 605-335-0357
http://CEM.cnasurety.com Email: uwservices@cnasurety.com
Northeast Agencies National Bond Program (31-21688)
An Allstate Commercial Expanded Market Program
Provide a copy of each owner's latest personal financial statement. If the personal
financial statement is more than 6 months old then provide us with a current statement.
Personal Financial Statements
Does the contractor have a formal bank line of credit?
Amount currently borrowed?
NoYes
If "Yes" amount of Line of Credit?
EXPERIENCE DATA
List the three largest contracts completed in the last five years:
Owner or General Kind of Work
Final
Gross Profit
Location
(City/County, State)
Contract
Price
Year
Completed
Owner or General Kind of Work
Date to be
Completed
Estimated
Gross Profit
Contract
Price
% of
Completion
Location
(City/County, State)
a. Failed in business or declared bankruptcy?
b. Failed to complete a job or been assessed with delay damages?
Any officer, owner or partner
Yes No
Yes No
. . .
. . . . . . . . . . . . . . . . . . .
Company
Yes No
Yes No
GENERAL DATA
Disputes, Financial Difficulties, Problems, Etc.
f.
c. Been involved in any lawsuits or disputes in the last 5 years? Yes No
. . . . .
Yes No
d. Do you have any corporate or personal assets
held in trust or escrow accounts?
Yes No
Yes No
. . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
Yes No
Yes No
e. Are any business or personal assets restricted or pledged
for any purpose (i.e. collateral for a loan, etc.)?
Yes NoYes No
Were you bonded in the past - By whom?
. . . . . . . . . . . . . . . . . . . . .
OPERATIONS DATA
Type of trades you perform:
Liability Insurance Company and Limits Expiration Date / /
Trades subcontracted:
Territory in which you perform work (present and planned)
Explain all "yes" answers fully below or attach explanation
Provide the company's last 2 years fiscal year-end financial statement or tax return. If
the latest fiscal year financial statement or tax return is more than 6 months old, then
also provide a current interim financial statement.
Company Financial Requirements
for (C) Corporations, (S)
Corporations, and LLCs:
Business Financial Requirement
for Sole Proprietorships and
Partnerships:
Provide the last 2 years fiscal year-end financial statement on the business. If the
fiscal year-end statement on the business is more than 6 months old, then also
provide us with a current interim financial statement.
E. That in the Event of Default: (a) the Surety shall have the right, but not the obligation, to take possession of the work under any Contract, to complete such Contract, or
cause or consent to the completion thereof, with any cost thereof being Loss; (b) the Indemnitors hereby assign, transfer, and set over to the Surety all of their rights under the
Contracts, including: (i) their right, title and interest in and to all subcontracts let in connection therewith; (ii) all machinery, plant, equipment, tools and materials upon the site of
the work or elsewhere for the purposes of the Contracts, including all material ordered for the Contracts; (iii) all patents, licenses, permits and computer software used for the
performance of any Contract and/or financial record keeping of the same; (iv) all actions, causes of action, claims and demands whatsoever relating to the Contracts; and (v)
any and all sums due under the Contracts at the time of the Event of Default or which may thereafter become due; (c) the Indemnitors hereby authorized the Surety to endorse
in the name of the payee, and to receive and collect any check, draft, warrant or other instrument made or issued in payment of any such sum, and to disburse the proceeds
thereof; and (d) the Indemnitors hereby irrevocably nominate, designate and appoint the Surety and its designees as their attorney-in-fact with all the powers necessary to
exercise any right granted in this Agreement, including but not limited to the power to make, endorse, execute, sign, and deliver any and all additional or other instruments,
checks, drafts, deposits, ACH and wire transfer directives and orders, change of address notices, liens and releases thereof, applications, certificates, draw requests, orders,
releases, and papers deemed necessary or desirable by the Surety in order to give full effect to the obligations assumed and the agreements made by Indemnitors hereunder,
the assignments and conveyances made herein, and the full protection intended to be herein given to the Surety under all the provisions of this Agreement. The Indemnitors
ratify and confirm all acts undertaken by the Surety and/or its designees as such attorney-in-fact.
Page 1 of 2
GENERAL INDEMNITY AGREEMENT
THIS AGREEMENT is made by the undersigned Indemnitors ("Indemnitors") for the benefit of Surety in connection with any Bond, as defined below, which may have been or
may hereafter be provided for the benefit of or at the request of any one or more Indemnitors. If any Indemnitors have previously executed an indemnity agreement in favor of
Surety, this Agreement shall be in addition to and not in lieu of or in replacement of such other agreement.
I. DEFINITIONS.
The following terms shall be defined as follows for purposes of this Agreement:
Form F9134-6-2018
A. Bond: Any surety bond, undertaking, or other obligation in the nature of a guaranty or suretyship, as well as alterations, amendments, extensions, substitutions, and
renewals issued or procured by the Surety on, before, or after the date of this Agreement for (a) any Indemnitor or any of their respective parent companies, subsidiaries, and
affiliates; (b) any joint venture, partnership, association, limited liability company, or other legal entity in which one or more of the persons and entities identified above in
sub-paragragh (a) have a direct or indirect interest; or (c) at the request of any Indemnitor.
B. Contract: Any contract or obligation whose performance is covered or guaranteed under a Bond.
C. Event of Default: Any one or more of the following: (a) any breach of the terms and conditions of this Agreement; (b) Principal's breach, abandonment or forfeiture of a
Contract; (c) any bankruptcy, insolvency, assignment for the benefit of creditors, appointment of a receiver or conservator, or similar proceeding concerning the Principal or any
Indemnitor, whether voluntary or involuntary.
D. Loss: Any (a) claim, demand, liability, charge, suit, fee, or expense, including but not limited to attorney (both outside and in-house) and consultant fees, incurred by
the Surety as a result of issuing or procuring a Bond; (b) cost incurred by Surety in procuring or attempting to procure a release from liability under a Bond; (c) cost incurred in
investigation or adjustment of any claim or potential claim under a Bond; (d) costs incurred by Surety in enforcing the Indemnitors' obligations under this Agreement; and (e) any
other cost incurred by Surety arising from the issuance or procurement of a Bond. The term Loss shall also include any advances or loans to any Principal or Indemnitor that
are not repaid to the Surety as required by the terms of such advances or loans.
E. Principal: The person(s) and entity (ies) whose Contract obligations the Surety is requested to guarantee by issuing or procuring a Bond. Principal includes any person
or entity identified on a Bond as "Principal" or "Contractor."
F. Surety: Any one or more of Western Surety Company, Universal Surety of America, and their successors, assigns, affiliates, subsidiary companies, and reinsurers.
The term Surety shall also include any other person or entity which, at the request of the above, may act as surety or co-surety on any Bond.
II. INDEMNITY. The Indemnitors agree:
A. To defend, indemnify, and save harmless Surety from and against any and all Loss Indemnitor which the Surety may pay or incur.
B. To pay Surety all premium due on Bonds at the rates and times specified by the Surety. The Indemnitors specifically acknowledge and agree that the Surety's right to
charge and collect premiums continues until the Surety is provided written evidence, satisfactory to the Surety that (i) its liability on such Bond has been discharged or (ii) its
termination of liability as a matter of law.
C. That in any claim or suit arising out of or related to any Bond or this Agreement, an itemized statement of Surety's loss and expense, sworn to by a representative of
Surety, or other evidence of disbursement by Surety, shall be prima facie evidence of the fact and extent of Indemnitor's liability under this Agreement.
III.
E. Claim Notices. Immediately upon becoming aware of any claim, demand, or proceeding concerning a Bond, the Indemnitors shall send notice of same to the Surety at:
D. To deposit collateral security with the Surety upon demand in an amount that Surety shall reasonably determine is necessary to protect it from Loss whether or not
Surety has made any payment.
G. That upon an Event of Default, the Indemnitors grant the Surety a security interest in all property, rights, and asserts of the Indemnitors, including, but not limited to, all
inventory, equipment, instruments, investments, contracts rights and proceeds, insurance, accounts, and deposits ("Collateral"). This Agreement shall constitute a Security
Agreement and a Financing Statement for the benefit of the Surety in accordance with the Uniform Commercial Code and any similar statute and may be so used by the Surety
without in any way abrogating, restricting or limiting the rights of the Surety. Indemnitors authorize the Surety upon an Event of Default to file this Agreement or a photocopy
thereof and any schedules or statements necessary to describe the Collateral covered by such filing.
F. That all payments earned on any Contract shall be held in trust as trust funds for the completion of the Contract and the payment of Indemnitors' obligations for labor,
material, equipment, supplies or services furnished in the performance of the Contract. Upon an Event of Default and the Surety's request, Indemnitors shall open an account
with a bank acceptable to the Surety for the deposit of such trust funds.
GENERAL PROVISIONS. The Indemnitors further agrees as follows:
A. Books and Records; Credit Reports. Upon demand and reasonable notice, the Surety shall be provided access to the books and record of the Indemnitors which
includes but is not limited to papers, books, records, contracts, reports financial information and electronically stored information for the purpose of review and copying. The
Surety is authorized to obtain a credit report on any Indemnitor at any time while the Surety may be liable under any Bond.
D. Prior Bonds. Indemnitors waive any defense related to the date of this Agreement's execution and acknowledge that any and all Bonds executed pursuant to any
Indemnitor's request before the date of this Agreement were executed by the Surety in reliance on this Agreement. Indemnitors understand and agree that this Agreement is a
continuing agreement to indemnify over an indefinite period.
B. Joint and Several Liability. Indemnitors' obligations under this Agreement are joint and several. Surety's release of any one Indemnitor shall not release any other
Indemnitor. No action or inaction of Surety with respect to anyone other than Indemnitor shall relieve the Indemnitor of any obligation owned under this Agreement. Indemnitor
shall not be released from liability under this Agreement because of the status, condition, or situation of any party to this Agreement or any Principal.
C. Defects in Execution. If the execution of this Agreement by any Indemnitor is defective or invalid for any reason, such defect or invalidity shall not affect the validity
hereof as to any other Indemnitor. Should any provision of this Agreement be held invalid, the remaining provisions shall retain their full force and effect.
F. Claim Settlement. Surety shall have the right in its sole discretion to decide whether any claims arising out of or related to any Bond shall be paid, compromised,
defended, prosecuted, or appealed regardless of whether or not suit is actually filed or commenced against Surety upon such claim. Absent Surety's intentional wrongdoing,
Indemnitor agrees to be conclusively bound by Surety's resolution of any and all claims and to accept Surety's determination of liability in regard to any and all claims.
CNA Surety Corporation, Claim Department
151 North Franklin, 17th Floor
Chicago, IL 60606
Page 2 of 2
(As listed on questionnaire)
All business submitted on this Indemnity Agreement shall be reviewed and underwritten by Western Surety Company,
P.O. Box 5077, Sioux Falls, SD 57117-5077
(1)
Dated:
(Month) (Day)
,
(Year)
,
Company Name
(Print)
:
(Printed)
Authorized
Signature
X
Title:
Title:
Indemnitor Type:
Personal
Spouse
Proper Indemnity:
John Doe, Indemnitor
Jane Doe, Indemnitor
(2)
Indemnitors: Signature X
Spouse: (Printed)(Printed)
Indemnitors: Signature X
Indemnitors: Signature X
Spouse: (Printed)(Printed)
Indemnitors: Signature X
Indemnitors: Signature X
Spouse: (Printed)(Printed)
Indemnitors: Signature X
Indemnitors: Signature X
Spouse: (Printed)(Printed)
Indemnitors: Signature X
Entity Type:
Sole Proprietor
Partnership
Corporation
LLC
Proper Indemnity:
John Doe, Owner
Jane Doe, Partner
John Doe, President
Jane Doe, Managing Member
G. Bond Declination. Surety may decline to execute any Bond for any reason and shall not be liable to Indemnitor, or any person or entity, as a result of such declination.
H. Termination. An Indemnitor may terminate liability to Surety under this Agreement by sending written notice by registered mail of intent to terminate to Surety, in care
of Western Surety Company, P.O. Box 5077, Sioux Falls, South Dakota 57117-5077. Termination will be effective twenty days after actual receipt of such notice by Surety, only
for Bonds signed or committed to by Surety after the effective date of termination.
I. Issuing Surety. Indemnitors understand and agree that other than for the entity issuing a Bond, no other entity included within definition of the "Surety" in this Agreement
assumes any obligation whatsoever with respect to either this Agreement or such Bond.
J. Electronic Image. An electronic image, printout, copy, or facsimile of this Agreement shall be considered an original and shall be admissible in a court of law to the
same extent as an original copy.
K. Bond Changes. The Indemnitors' obligations to the Surety shall remain unchanged in the event of any changes in any Bond without regard to notice or consent by any
Indemnitor. The Surety shall have no obligation to give the Indemnitors notice of the execution, renewal, or modification of a Bond.
L. Other Agreements. Indemnitors agree that this Agreement is not a replacement, release, or alteration of any other agreement between any Indemnitor and the Surety
but shall be in addition to such other agreement unless expressly stated otherwise herein.
M. Amendment; Assignment. This Agreement may not be altered or amended except by a writing executed by the Indemnitors and the Surety. This Agreement and the
Indemnitors' obligations hereunder may not be assigned without the prior written consent of the Surety.
N. Date of Agreement. The date of this Agreement shall be the earliest date that any Indemnitors executes this Agreement.
PLEASE NOTE: Indemnity is required of the entity AND all owners and spouses personally. (1) Provide the
indemnity of the entity by dating and signing with authorized title below. (2) All owners and spouses must sign as
personal indemnitors. Refer to the boxes at right for examples of proper indemnity by indemnitor type. BY
SIGNING THIS INDEMNITY, INDEMNITORS ARE ACKNOWLEDGING THEY HAVE READ AND ARE AGREEING TO
BE BOUND BY ALL OF THE TERMS AND CONDITIONS ON PAGES ONE AND TWO OF THIS DOCUMENT.
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