J.R. OLSEN BONDS & INSURANCE BROKERS, INC.

7407 Topanga Cyn Blvd, Canoga Park, CA 91303
Toll Free: (800) 452-7121 ~ Fax: (818) 227-2628 ~ Broker/Agent License #0680914

Multi-Purpose Automated License & Permit Bond Application
Fair Reporting Act Notice: In making this application for surety it is understood that an investigative consumer report may be prepared whereby pertinent information concerning your character, reputation, personal characteristics and mode of living may be obtained. Information as the nature and scope of this report may be obtained upon written request.
** ALL APPLICANTS ARE SUBJECT TO CREDIT REVIEW **
All entry areas with a red asterisk * MUST BE ANSWERED

If you are working with an Agent on this bond, please enter the Agent's information below
Agent's Business Name:
Agent's Phone: Person to Contact at Agency:
Agent's Email Address:
Type of Bond:*  
Bond for what State? *
Bond Amount:* $  
Bond Effective Date:* / /
PERSONAL INDEMNITOR #1 -- aka OWNER #1
  Owner - #1: Full Name: *  
Title:* Marital Status: *  
  DBA Name (if different):
  Owner - #1: Social Security Number: *  
  Owner - #1: Home - Street Address: *  
  Owner - #1: Home - City: *    State: *  
  Owner - #1: Zip Code: *    
  Owner - #1: Phone Number: *  
  Owner - #1: Email Address (this email address will get a copy of this application)
*    
Additional information that will expedite your application
         Obligee Name:
         Years of experience as Owner of this Business:
         Related Management Experience (in years) ?
         Any prior claims?          Was claim resolved?
Important conditions - read and click 'agree' or 'do not agree' below
The Undersigned Applicant and indemnitors hereby certify that the statements contained herein or attached hereto are true and are made to induce the Surety to execute or continue the suretyship described herein, and agree as follows; FIRST: to pay any premiums due while Surety has liability outstanding; SECOND: to indemnify Surety from all liability and loss, expenses, and damages incurred as a result of furnishing bond, renewals, continuations, extensions, or increase in bond amount, including attorneys fees incurred by Surety in enforcing this agreement; THIRD: that Surety has the exclusive right to determine the disposition of any claim or suit; FOURTH: that an itemized statement of loss and expenses by Surety shall be prima facie evidence of the fact and extent of Undersigned's obligation to Surety; FIFTH: that this agreement inures to the benefit of the Surety, or any other company executing or reinsuring bond at the request of Surety; SIXTH: that Surety may examine assets covered by the bond any time; SEVENTH: that in the event application is for a lost securities bond, Undersigned will deliver any securities subsequently found to Surety: and EIGHTH; upon demand of Surety, Undersigned will deposit sufficient collateral with Surety to offset any claim made against Surety under bond applied for. J.R. Olsen Bonds & Insurance Brokers, Inc. is authorized by indemnitors to designate the surety executing this bond, substitutions, or amendments thereto. This agreement shall apply to all renewals, continuations, substitutions, and extensions of suretyship herein applied for. IT IS HEREBY FURTHER AGREED AND UNDERSTOOD THAT THE FIRST'S YEAR'S PREMIUM ON THE BOND SHALL BE CONSIDERED FULLY EARNED UPON ISSUANCE OF THE BOND. ** All applicants are subject to credit review.
PERSONAL INDEMNITOR #1


 

Signed and dated this day of ,
PERSONAL INDEMNITOR #2
spouse of #1 above, or additional owner or additional owner's spouse
In order for your application to be processed, you must check "I Agree" below

Social Security Number:
First Name: Last Name:
Street Address:
City: State: Zip:
PERSONAL INDEMNITOR #3
additional owner or additional owner's spouse
In order for your application to be processed, you must check "I Agree" below

Social Security Number:
First Name: Last Name:
Street Address:
City: State: Zip:
PERSONAL INDEMNITOR #4
additional owner or additional owner's spouse
In order for your application to be processed, you must check "I Agree" below

Social Security Number:
First Name: Last Name:
Street Address:
City: State: Zip:
PERSONAL INDEMNITOR #5
additional owner or additional owner's spouse
In order for your application to be processed, you must check "I Agree" below

Social Security Number:
First Name: Last Name:
Street Address:
City: State: Zip:
PERSONAL INDEMNITOR #6
additional owner or additional owner's spouse
In order for your application to be processed, you must check "I Agree" below

Social Security Number:
First Name: Last Name:
Street Address:
City: State: Zip:
When finished entering the information, click the 'Submit Application' button below.
and you will receive an indication in red print that the application was either sent to us,
or that certain areas were not answered and need entering.