Insurance Probate Bond Application

INSURANCE PROBATE BOND APPLICATION

Applicant Name:

Applicant / Insured Information

Individual Corporation Partnership Trust Other:

Month: Day: Year:

Decedent / Estate Information

Date of Death: Month Day Year

Executor Administrator Guardian Conservator Trustee Other:

Inventory Filed: Yes No

Bond Details

Effective Date: Month Day Year

Indemnitors and Additional Parties

Indemnitor 1

Indemnitor 2 (if any)

Indemnitor 3 (if any)

Coverage, Conditions and Exclusions

Coverage Requested: Fiduciary/Executor Bond Guardianship Bond Conservator Bond Trustee Bond

Exclusions and Conditions: The surety shall not be liable for losses arising from fraud, willful misrepresentation by the principal, punitive damages, criminal conduct, or any liabilities exceeding the penal sum of the bond. The issuance of the bond is conditioned upon the truthfulness of the statements in this application, satisfactory investigation results, and the execution of an indemnity agreement in favor of the surety on terms acceptable to the surety. The applicant acknowledges that the surety may require collateral and may pursue indemnitors for any claims paid or expenses incurred in connection with the bond.

Supporting Documentation Checklist

Death certificate
Certified copy of Will (if any)
Letters testamentary / Letters of administration
Inventory or estimated accounting of assets
Appraisals of significant assets
Photo identification for applicant
Trust documents (if trustee)
Court order appointing guardian or conservator (if applicable)
Other documents:

Declaration, Authorization and Indemnity

I, the Applicant, declare under penalty of perjury that the information contained in this application is true and complete to the best of my knowledge. I authorize the surety and its representatives to make such investigations and inquiries as they deem necessary, including obtaining credit reports and investigating the financial condition of the applicant and indemnitors. I agree to execute and deliver the surety's standard Indemnity Agreement and any ancillary documents required by the surety as a condition to issuance of the bond and to indemnify and hold harmless the surety from any loss, cost, damage or expense (including attorneys' fees) incurred by the surety by reason of issuing, maintaining, enforcing or attempting to enforce the bond or any claim against it.

I understand and agree that the surety may, at its option, cancel the bond and seek recovery from the principal and indemnitors for all amounts paid under the bond and all costs, interest and fees arising from claims. I further consent to the jurisdiction and venue of the courts where the obligation is enforced and waive any defenses relating to forum non conveniens.

By signing below I certify that I have authority to apply for the requested bond and to bind the applicant to the terms of this application and any indemnity agreement required by the surety.

Acknowledgement of Fraud and Penalties

Applicant acknowledges that making a false statement in this application may constitute fraud and may subject the applicant to civil or criminal penalties under applicable law. The surety reserves the right to deny, rescind or seek restitution for bonds issued where material misrepresentation is discovered.

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