AGENT USE ONLY
BOND NUMBER
HCC SURETY GROUP
CALIFORNIA BUSINESS / JANITORIAL SERVICES APPLICATION
A
BOND INFORMATION
TYPE OF BUSINESS

NUMBER OF EMPLOYEES

Business Services
Janitorial Service
TYPE OF SERVICE
REQUESTED EFFECTIVE DATE
B
BUSINESS INFORMATION
BOND AMOUNT REQUESTED






$2,500
$5,000
$7,500
NAME OF BUSINESS
BUSINESS PHONE
STREET ADDRESS
BUSINESS FAX
CITY/ STATE/ ZIP
EMAIL ADDRESS
C
ADDITIONAL INFORMATION
Have you had any employee dishonesty losses in the past five years?
If yes, please explain (attach separate sheet if needed)
$10,000
$25,000
Other $
 YES  NO
Undersigned are required to sign individually.
The under signed c ertify t he ab ove information i s t rue an d c orrect. T he ap plicant h ereby warrants t hat, t o t he b est of
his/her/its knowledge, no facts currently exist which could reasonably give rise to a claim against this policy.
Signed, sworn to and dated this _______ day of ___________________ , _______ .
X [Signature]
X
PRINT NAME
PRINT NAME
AUTHORIZED REPRESENTATIVE AND INVIDUALLY
EMAIL ADDRESS
DATE OF BIRTH
DRIVERS LICENSE
SOCIAL SECURITY NUMBER
AUTHORIZED REPRESENTATIVE AND INVIDUALLY
EMAIL ADDRESS
DATE OF BIRTH
DRIVERS LICENSE
HOME ADDRESS
HOME ADDRESS
CITY/ STATE/ ZIP
CITY/ STATE/ ZIP
SOCIAL SECURITY NUMBER
Bonds issued by American Contractors Indemnity Company
Bond Amount
$2,500
$5,000
$7,500
$10,000
$25,000
One Year
$50.00
$75.00
$100.00
$125.00
$250.00
Employees over 5
+$1/ employee
+$2/ employee
+$3/ employee
+$4/ employee
+$5/ employee
Rates
Three year premium is 2.25 times the annual rate
First years premium is fully earned upon issuance
Example of premium calculation for
$7,500 bond amount, 8 employees
for one year term
One year ($7,500)
3 employees at $3
Total Annual Premium
Agent Name:
Phone:
Address:
Fax:
City,State, Zip
$100.00
$9.00
$109.00
HCCS Prod No.
Visit us at hccsurety.com for more information
HCCS Revision 2011/03