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Surety Solutions A Gallagher Company

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Surety Bond Application

Step 1 of 5

20%

Bond Information
Type of Bond:*
Amount of Bond:*
Effective Date:*
MM slash DD slash YYYY
Obligee Name:*
The entity requiring you to get this bond.
Obligee State:*
Bond Term:*
The length of time your bond is to remain active. Typically, bond terms are set at one year and renew annually.

Business Information
Company Name:*
Business Phone #:*
Company Address:*
Street Address Address Line 2 City State ZIP Code
Business Net Worth:*
License #:
Business Type:*
- Proprietorship
- Corporation
- Partnership
- LLC
Date Formed:*
MM slash DD slash YYYY
Do you have a Federal Employer Identification Number (FEIN)?*
- Yes
- No
What is your Federal Employer Identification Number (FEIN)?*
Number of Owners, Partners or Members:*
How long in business?*
License Classification:
Business Fax #:
Previous Bonding Company:
Business Email Address:*
Enter Email Confirm Email

Personal Information
Applicant's Name:*
Applicant's Social Security #:*
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.
Applicant's Date of Birth:*
MM slash DD slash YYYY
Is the applicant married?*
- Yes
- No
Spouse's Name:*
Spouse's Social Security #:*
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.
Spouse's Date of Birth:*
MM slash DD slash YYYY
Residence Address:*
Street Address Address Line 2 City State ZIP Code
Personal Net Worth:*
Personal Email:*
Enter Email Confirm Email
Do you own or rent?*
- Own
- Rent
Mortgage Amount:
Is there another business owner?*
- Yes
- No

Personal Information
Please enter information for the other business owner.
Applicant's Name:*
Applicant's Social Security #:*
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.
Applicant's Date of Birth:*
MM slash DD slash YYYY
Is the applicant married?*
- Yes
- No
Spouse's Name:*
Spouse's Social Security #:*
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.
Spouse's Date of Birth:*
MM slash DD slash YYYY
Residence Address:*
Street Address Address Line 2 City State ZIP Code
Personal Net Worth:*
Personal Email:*
Enter Email Confirm Email
Do you own or rent?*
- Own
- Rent
Mortgage Amount:

Has / Does the Business or Owner(s)?
Please answer the following questions for the business or owner(s).
Has any prior surety company ever cancelled, refused renewal or denied an application for the applicant?*
- Yes
- No
Please Explain:*
Has the applicant ever filed bankruptcy?*
- Yes
- No
Please Explain:*
Has the applicant ever had a license suspended, revoked, denied or has any legal or administrative actions?*
- Yes
- No
Please Explain:*
Has the applicant had a prior surety pay a bond claim?*
- Yes
- No
Please Explain:*
Has the applicant or any company owned by the applicant ever failed in business?*
- Yes
- No
Please Explain:*
Does the applicant have any pending or open lawsuits, judgements, liens or past due child support obligations?*
- Yes
- No
Please Explain:*
Has the applicant ever been convicted of fraud or felony?*
- Yes
- No
Please Explain:*
Were you referred to us by Arthur J. Gallagher & Co.?*
- Yes
- No
Consent*
All information furnished on this application will be utilized and relied upon in the issuance of any bond on or after today's date. 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 from the applicant.
I Agree
Hidden
What is today's date?*
MM slash DD slash YYYY

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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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