Agency Bond Form - ZipBonds Staging

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User ID

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Account ID

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Referring Agency Account ID

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Max Bond Penalty Amount

Unique ID

MSA-Bond Number

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Use Main Street PDF

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Auto Generate Forms

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Auto Generate AND Company Signature

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Referring Agency

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Referring Agency

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Agency URL Parameter

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Referring Agent

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Agency Contact Email

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Gravity View - Referring Agency

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Demo Surety Co

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Demo Trade

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Demo Bond #

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Accept Payment

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Select Pay Print

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Select Pay Print Translation

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Bond Class

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Zip ID

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MainStreet Unique ID

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Old Republic Unique ID

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Record Type ID (Application)

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Record Type ID (Opportunity)

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Record Type ID (Bond)

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Intake Form Check

For Javascript

Select Lead Source*

Agency Name*

Other Agency (Not Listed):

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Intake Form Notification Object (JavaScript)

Generic Form Description*

What type of bond are you looking for?

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POA Agent Conditional

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POA Agent

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POA Agent Email

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State for ERISA Check

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State

State*

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State

Bond Type

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Class Code

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Renewal

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Bond Penalty

Bond Penalty*

ERISA Bond Penalty*

Bond Penalty*

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Consolidated Bond Penalty (ERISA and Normal)

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Issuing Carrier

The Admin Label "carrier" must be here for the issuing carrier information to correctly transfer to the pdf.

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Billing Carrier

The Admin Label "carrier" must be here for the issuing carrier information to correctly transfer to the pdf.

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Fixed or Variable Term Years

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Bond Term

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Max Bond Term (For Filters)

Bond Term

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Bond Term

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Bond Term

Bond Term*

Bond Term

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Obligee

ERISA Premium

Start Date

Expiration Date

Specified Expiration Date

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Specified Exp Date for Conditionals and JavaScript

This bond has a specified expiration date that will expire the same year unless purchased after expiration date of current year, then it will expire the next year on date listed.

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Bond Penalty Amount

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Premium (1 Year)

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Broker Fee

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Broker Fee

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Hidden Bond Premium for Javascript and Dropdowns

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Premium label from Database

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Premium for Bond Penalty Dropdown Separator

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Premium (No Broker Fee)

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Percentage of Penalty for Premium

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Premium

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Premium for Fixed JS

Premium

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Premium no broker fee - multiplied by term

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Calculated Broker Fee Step 1

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Final calculated premium for bond__c

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Calculated Broker Fee Step 2

Premium (per location)

Number of Locations*

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Total Bond Penalty

1 - Location Name*

2- Location Name*

3- Location Name*

4- Location Name*

5- Location Name*

Obligee / Project Owner

Business Information

Is this a business?

Yes
No

Business or Individual Name*

Business Address*

Street Address Address Line 2 City State ZIP Code

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Business Information (yes/no)

Business Type*

Business Tax ID*

Number of Employees*

Contractor License Type

Years in Business*

Largest Completed Project*

Do you operate under another business name?*

DBA Name*

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Officer/Owner Information

Texas Tax ID Number*

Owner/Partner*

First Middle Last

Years of Experience*

Owner Social Security Number*

Owner Date of Birth*

Is the Owner a US Citizen*

Owner Residential Address*

Street Address Address Line 2 City State ZIP Code

Owner Email*

Owner Phone Number*

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CA WA State Contractor's License #

State Contractor's License # or UBI*

Subdivision Bond

City, County, or State that is requiring the bond*

Public Improvements Agreement or Engineer's Estimate of Improvements

Drop files here or

Max. file size: 256 MB.

ERISA Bond

Does this plan cover union funds and/or multi-employer funds?*

Does this plan contain any non-qualifying assets and/or ESOP-Employer Securities as defined by ERISA?*

Has this plan suffered any dishonesty losses?*

Name of Employee Benefit Plan:*

Plan Sponsor:*

Plan Sponsor Address:*

Street Address Address Line 2 City State ZIP Code

NPI #*

NSC/PTAN Number

Has the company, any predecessor company or any owner ever been in bankruptcy?*

Has the company, any predecessor company, or any owner ever had a paid claim with a surety company?*

Has the company, any predecessor company, or any owner ever been involved in any lawsuits within the past 7 years?*

If yes to any of the 3 previous questions, please describe further:

Date of Accreditation

Accreditation Organization

# years participating in Medicare

Please enter a number from 1 to 100.

Approximate amount of Medicare billing last year*

Approximate amount of Medicare billing two years ago*

Approximate amount of Medicare billing expected next year*

Date of last audit by Medicare

Any citations or problems reported?*

Please describe further:

Has applicant, any predecessor company, any owner or officer ever had a Medicare or Medicaid license revoked, or experienced an adverse legal action relative to Medicare or Medicaid?*

Please describe further:

License Number*

License Issuing State

Lost Instrument Information

Description of Lost Instrument*

Where Was The Instrument Last Seen?*

Date of Loss*

Court and Probate Bond Information

Bond Type*

Administrator

Independent
Dependent
Not Indicated

What Bond Type?*

Current Occupation*

Case Number*

Hearing Date*

Name of Court*

Attorney Name*

First Last

Firm Name*

Title Information

Owner Social Security Number*

Value of the Vehicle*

Vehicle Make*

Vehicle Model

Vehicle Body Style

Vehicle Year*

Vehicle Identification Number*

Is there a lien on the vehicle that is less than 10 years old?*

Upload Bill of Sale and Other Vehicle Documents

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Max. file size: 256 MB.

Contract Bonds

Contract Bond Options*

Contract Bond Up To $750,000
Contract Bond Over $750,000

Contract Bond

What type of work do you do?*

Other

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Project Owner*

Bond Information

Required Maintenance Period*

Other/Flat Rate Bond Amount

Have you had a surety bond before?*

Prior Surety Company

Other Surety Company

Who is your general liability insurance company?*

Other Standard Company

Other Non-Standard Company

Have you had a prior surety loss?*

Has the applicant ever had a bond claim filed or paid against them?*

Have you, the applicant, or any owner of your business ever filed bankruptcy?*

Do you have any outstanding tax liens or judgments against you?*

Are there any current legal sanctions or pending lawsuits against you or your business?*

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Ownership Structure

Officer/Owner Information

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Percent of Business Owned

Please enter a number from 0 to 100.

How many business partners do you have?*

Business Partner 1 Name*

Business Partner 1 Social Security Number*

Date of Birth*

Is Business Partner 1 a US Citizen?*

Business Partner's 1 Address*

Street Address Address Line 2 City State ZIP Code

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Business Partner 1 Percent of Business Owned*

Please enter a number from 0 to 100.

Business Partner 1 Years of Experience*

Business Partner 2 Name

Business Partner 2 Social Security Number*

Date of Birth

Is Business Partner 2 a US Citizen?*

Business Partner's 2 Address*

Street Address Address Line 2 City State ZIP Code

Business Partner 2 Percent of Business Owned*

Please enter a number from 0 to 100.

Business Partner 2 Years of Experience*

Business Partner 3 Name

Business Partner 3 Social Security Number*

Date of Birth

Is Business Partner 3 a US Citizen?*

Business Partner's 3 Address*

Street Address Address Line 2 City State ZIP Code

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Business Partner 3 Percent of Business Owned*

Please enter a number from 0 to 100.

Business Partner 3 Years of Experience*

Business Partner 4 Name

Business Partner 4 Social Security Number*

Date of Birth

Is Business Partner 4 a US Citizen?*

Business Partner's 4 Address*

Street Address Address Line 2 City State ZIP Code

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Business Partner 4 Percent of Business Owned*

Please enter a number from 0 to 100.

Business Partner 4 Years of Experience*

Contact Information

Same as Officer/Owner Information?

Same as Officer/Owner Information?

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Same as Officer/Owner Information?

Yes
No

Name*

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Hidden Principal Name*

Phone Number*

Email*

Billing Address*

Same as Business Address

Street Address Address Line 2 City State ZIP Code

Upload Financials and Contract

Please upload your most recent business financial statement, personal financial statement, as well as a copy of the current contract you plan to bid on if applicable.

Drop files here or

Max. file size: 256 MB.

Upload Bid Specs or Copy of the Contract

If you have any upcoming bond need, please upload the bid specs or a copy of the contract

Drop files here or

Max. file size: 256 MB.

Consent Box*

Disclaimer:
By checking this box, I attest that all information provided above is accurate and honestly represented. I agree to the terms and conditions, acknowledge the privacy policy and agree to its terms. Furthermore, you confirm authorization to the “ZipScore” underwriting model which may obtain your credit profile from any consumer reporting agency, confirm your identity, and to enable any consumer reporting agency to monitor your credit for changes that directly impact ongoing bond capacity”*

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Pay Now or Later

Pay Now or Later?

Now
Later

Bond Payment

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Wet/Company Signature?

This contract will be shipped to you as the city requires a physical signature.

Shipping Address*

Same as Business Address

Street Address Address Line 2 City State ZIP Code

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Subtotal for Calculation

Shipping

Price of Bond

Price: $0.00

Price of ERISA Bond

Price: $0.00

DMEPOS Price

Price: $0.00

Choose Payment Type:*

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Payment Received

payment received

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Payment Received Date

Site Fee

Price: $0.00

Site Fee

Price: $0.00

Total

$0.00

ACH*

Account Number Account Type Routing Number Account Holder Name

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Invoice #

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End of Form

* This specific bond requires a wet signature and must be mailed to you.

← Go Back

Select. Pay. Print.

Business Information

Business Information (yes/no)

Officer/Owner Information

Officer/Owner Information

CA WA State Contractor's License #

Subdivision Bond

ERISA Bond

Lost Instrument Information

Court and Probate Bond Information

Title Information

Contract Bonds

Contract Bond

Bond Information

Ownership Structure

Officer/Owner Information

Contact Information

Pay Now or Later

Bond Payment

End of Form