Bond Application Form

BOND APPLICATION FORM

This Bond Application and Indemnity Agreement (the "Application") is submitted by Applicant Name: (Applicant) to Surety Name: (Surety) on Date: .

RECITALS

WHEREAS, Applicant seeks issuance by Surety of a bond or bonds guaranteeing performance or payment as required by Obligee; and

WHEREAS, Surety is willing to consider issuing such bond(s) conditioned upon the receipt of a completed application, satisfactory underwriting, and execution of this Application and any accompanying indemnity agreement; and

WHEREAS, Applicant acknowledges that issuance of bond(s) by Surety is discretionary and contingent upon Applicant's acceptance of the terms, conditions and indemnities set forth herein;

NOW, THEREFORE, in consideration of Surety's review and potential issuance of bond(s), Applicant and Surety agree as follows.

1. APPLICATION FOR BOND

Applicant requests issuance of the following bond(s):

2. APPLICANT IDENTIFICATION

Business or Individual Name:

Individual   Corporation   Limited Liability Company   Partnership

3. FINANCIAL INFORMATION & DOCUMENTS

Applicant represents and warrants that all financial statements, tax returns and other information provided to Surety are true, accurate and complete. Applicant authorizes Surety and its representatives to obtain credit reports and any other financial information necessary to underwrite the risk.

Financial statements   Tax returns   Bank references   Other (see details)

4. REPRESENTATIONS, WARRANTIES AND AUTHORIZATIONS

Applicant represents and warrants that Applicant is authorized to execute this Application and that no litigation, judgment, tax lien or bankruptcy proceeding exists other than as disclosed in writing. Applicant authorizes any bank, trade creditor, accountant, attorney, or other person to release information requested by Surety for underwriting. Applicant acknowledges that Surety may rely on the information for the issuance or denial of bond(s).

Applicant additionally certifies that the following material facts exist or are disclosed:

5. INDEMNITY AND REIMBURSEMENT

As a condition to issuance of any bond(s), Applicant (and each person or entity executing this Application as indemnitor) agrees to indemnify, defend, and hold harmless Surety from and against any and all losses, liabilities, claims, demands, costs and expenses (including attorneys' fees and costs of investigation) which Surety may sustain or incur by reason of issuing or procuring any bond(s) for Applicant. Applicant shall, on demand, pay Surety all such amounts and shall provide collateral or security as requested by Surety.

Applicant acknowledges that Surety's obligations under any bond are secondary to Applicant's obligations under this indemnity and that Surety shall be subrogated to all rights of the Obligee against Applicant to the extent of any sums paid by Surety.

6. PREMIUM, FEES AND PAYMENT

Applicant agrees to pay Surety premium, fees, collateral deposits and costs as required by Surety's underwriting. Premium and fee estimates are non-binding and actual charges shall be confirmed in writing. Premium: . Payment Terms:

7. CLAIMS, NOTICES AND REMEDIES

Any claim or demand by Applicant or Surety relating to the bond or this Application shall be made in writing and delivered to the addresses set forth below. Applicant shall promptly notify Surety in writing of any claim asserted against Applicant that could give rise to a claim against the bond. Applicant consents that Surety may settle any claim without prior consent of Applicant and that settlement shall not relieve Applicant of indemnity obligations.

8. RECORDS, ACCESS AND INSPECTION

Applicant shall allow Surety and its agents access to Applicant's books, records, and premises for inspection and audit as reasonably required by Surety to evaluate, underwrite, or investigate any bond or claim. Applicant shall preserve records for a minimum of five (5) years or as required by law.

9. GOVERNING LAW; VENUE

This Application, any indemnity agreement accompanying it, and any bond issued in reliance hereon shall be governed by and construed in accordance with the laws of the State of without regard to conflict of laws principles. Venue for any action arising hereunder shall lie in the courts of that state.

10. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT; WAIVER; COUNTERPARTS

This Application, together with any indemnity agreement, exhibits and attachments referenced herein, constitutes the entire agreement between Applicant and Surety with respect to the subject matter and supersedes all prior agreements and understandings. If any provision is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. No amendment or waiver shall be effective unless in writing signed by the party to be charged. This Application may be executed in counterparts, each of which shall be deemed an original.

11. CERTIFICATION

Applicant certifies under penalty of perjury that the information provided in this Application and all attachments is true, complete and accurate to the best of Applicant's knowledge and belief. Applicant understands that Surety will rely upon such information in deciding whether to issue bond(s) and that misrepresentation or omission of material facts may be grounds for denial of coverage or for denial of bonds previously issued.

ACKNOWLEDGMENT AND AUTHORIZATION

By signing below, Applicant authorizes Surety to obtain credit reports, verify employment and banking information, and contact references and vendors. Applicant further acknowledges that issuance of any bond is subject to Surety's sole underwriting judgment and that premium and collateral requirements may be imposed as conditions precedent to issuance.

Applicant acknowledges receipt of a true copy of any bond issued and agrees to return any bond to Surety upon demand. Applicant agrees that any payment or performance by Surety under any bond shall create and be accompanied by the immediate right of Surety to subrogation, assignment, and reimbursement from Applicant.

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