AL Auto Dismantler and Parts Recycler Bond – Application

AL Auto Dismantler and Parts Recycler Bond – Quote

Step 1 of 2

Contact person: *

First

Last

Email *

Phone *

Business / Organization *

Applicant Name: (Exactly as it should appear on the Bond) *

Type of Entity: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Bond Type

AL Auto Dismantler and Parts Recycler Bond

Effective Date: *

Bond Amount $: *

Has the business or any of the owners involved in: (If yes, provide details) *

Had any lawsuits, liens or judgements against them?
Ever failed in business or declared bankruptcy?
Ever been convicted of a crime?
Ever had their license suspended, revoked or denied?
Ever been party to a surety bond claim?
Ever had a bond declined or cancelled?
None of the above

If yes, provide details below.

Owner Information:

Owners Name *

First

Last

Home Address:

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number (Our Website is Secure) or we'll call you for this information

Married

Single
Married

Home Phone:

# of years you have owned this business:

% of ownership

Please list any additional owners or partners: Name, Address and phone number: % of ownership

Disclaimer:

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerning any materiel fact whereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil penalties. By submitting this application, the owners listed above hereby authorize Surety Ins Inc, (including any of its representatives, affiliates, agents or designees) to conduct any and all investigative inquiries but not limited to obtaining consumer credit reports.