Freight Broker Bond Application

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BMC-84 Freight Broker Bond Application

Step 1 of 5

20%

What is your full name?*
Please enter the applicant's full name.
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What type of Surety Bond do you need?*
Hidden
How much is the bond amount?*
Please select the bond effective date.*
MM slash DD slash YYYY
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What is the Obligee's name?*
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Select the length of the bond term.*
- 1 Year Term
What is your email address?*
Enter Email Confirm Email

What is your phone number?*
What is your date of birth?*
MM slash DD slash YYYY
Were you referred to us by Arthur J. Gallagher & Co.?*
- Yes
- No
What is your Social Security Number?*
You're on a secure network. We need your SS# to pull credit. This is a soft pull that does not adversely affect your credit score.
Are you married?*
- Yes
- No
What is your spouse's full name?*
What is your Spouse's Social Security Number?*
You're on a secure network. We need your spouse's SS# to pull credit. This is a soft pull that does not adversely affect their credit score.

The surety company requires this to ensure you, as the principal, don't transfer assets to your spouse in the event of a claim.
What is your spouse's date of birth?*
MM slash DD slash YYYY
What is your residential address?*
Street Address City State ZIP Code

What is your company's name?*
Must be exactly as it appears on bond.
What is your business phone number?*
What is your company's address?*
Street Address City State ZIP Code
What is your company's net worth?*
What is the nature of your business?*
- Corporation
- LLC
- Partnership
- Proprietorship
What date was your company formed?*
MM slash DD slash YYYY
How many owners, partners and / or members of your business?*
How long have you been in business?*
What is your business fax number?
What is your FEIN / Tax ID?*
What is your MC number?

Your Motor Carrier number (required) - if you don’t have your MC number yet, the surety can still quote the bond for you, but we can’t actually write it until you do have that number.
Does your business have any additional owners or partners?*
- Yes
- No

Please answer the following questions about the additional owner or partner.
What is his/her full name?*
What is his/her Social Security Number?*
You're on a secure network. We need his/her SS# to pull credit. This is a soft pull that does not adversely affect their credit score.
What is his/her date of birth?*
MM slash DD slash YYYY
Does he/she have a spouse?*
- Yes
- No
What is his/her spouse's full name?*
What is his/her Spouse's Social Security Number?*
You're on a secure network. We need their spouse's SS# to pull credit. This is a soft pull that does not adversely affect their credit score.

The surety company requires this to ensure they, as an additional partner/owner, don't transfer assets to your spouse in the event of a claim.
What is his/her spouse's date of birth?*
MM slash DD slash YYYY
What is his/her residential address?*
Street Address City State ZIP Code

Are you or another owner/partner the Trustee, Trustor or Beneficiary of any Trust?*
- Yes
- No
Please provide a full explanation.*
Have you or another owner/partner ever declared bankruptcy?*
- Yes
- No
Please provide a full explanation of the bankruptcy.*
Do you or another owner/partner have any pending or prior IRS Liens?*
- Yes
- No
Please provide a full explanation of the IRS Liens.*
Do you or another owner/partner have any lawsuits pending?*
- Yes
- No
Please provide a full explanation of the lawsuits pending.*
Have you or another owner/partner ever been declined for bonding previously?*
- Yes
- No
Please provide a full explanation on the previously declined bond.*
Please consent to the information below:*
All information furnished on this application will be utilized and relied upon in the issuance of any bonds on or after the date above.

By submitting this application you acknowledge & authorize the procurement and use of a credit report for the individuals and/or business listed above.

If submitted by a 3rd party, you acknowledge & agree that you have authorization by the applicant.
I agree to the above statement.

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Contact Surety Solutions, A Gallagher Company

Email: customercare@suretysolutions.com

4285 Commercial Street SE
Suite 110
Salem, OR 97302

(866) 722-9239

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