Surplus Lines Broker Bond

To become a surplus lines broker you will need to get a license from your local government.

Getting this license you will undergo several background checks and criminal history check before being allowed to ‘set up shop.’ You will also be required to have a bond policy in place to be able to obtain the license. You may choose to self-bond your venture through a bank, but if you do not have the financial stability to be able to do this, you can purchase a bond from a broker.

The bond is not to protect the broker, but to protect others from any illegal practices or negligent acts that your business may engage in throughout the term of your license.

A surplus lines broker is an insurance agent that is able to sell policies to businesses and individuals that are not available in the state that they are licensed to practice in. If a Surplus lines broker were to sell a business an insurance policy that was not correct or legal to be in place in a certain area, any financial loss that the business may suffer can be quickly rectified by use of the bond arrangement.

It is important to know that a Surplus lines broker bond is not an insurance policy, but rather a way to access a lump sum of cash quickly should you be found to have committed any kind of fraud or negligence. After your bond broker repays any financial loss to the client, you will then need to reimburse the bond broker for the entire amount as well as any legal costs incurred.


Application for


Current or expiring quote we are looking to beat:


Name of previous surety company writing to the bond:


Section I: Bond Applied for

Type of Bond

Effective Date

Expiration Date


Type of Company

CORP

LLC

DBA

Partnership

Bond Amount


(Obligee)


Obligee Address


Section II: General Information

Applicant's Name

Spouse Name


SS#

Spouse SS#

Home Phone


Residence Address

City

State

Zip


Status of Residency

Own

Rent

At Current Address Since


Date of Birth

Spouse Date of Birth

Business License Number


Business Name


Business Phone

Business Fax

Business Email


Business Address

City

State

Zip


Date Business BEGAN Under Present Individual or Firm Name

Business Tax ID


Has any company refused to issue bonds for any purpose?

Yes

No

Do you have any liens, claims or judgements against you?

Yes

No


Has applicant ever failed in business?

Yes

No

Has applicant filed bankruptcy in the last 10 years?

Yes

No


If yes, Chapter 7?

Yes

No

Chapter 11?

Yes

No

Chapter 13?

Yes

No


Date Filed for Bankruptcy?


Date of Discharge?


If yes to any, please explain:


Section III: Additional Parties

Name

Spouse Name


SS#

Spouse SS#

Home Phone


Home Address

City

State

Zip


Personal Financials

(if more than one owner, each has to fill out this app)

Statement of assets and liabilities as of


Assets Liabilities
Cash in Bank Notes Payable to Banks
Cash on Hand Notes to Others(excl. of equipment)
Stocks and Bonds Accounts Payable
Accounts Receivable Federal and State Income Tax Due
Notes Receivable All Other Taxes
Inventory Accruals, Payrolls, Etc.
Cash Value Life Insurance    
Equipment Due on Equipment
Real Estate Due on Real Estate
Other Assets Other Liabilities
    Surplus and Undivided Profits
    Capital Stock(if a corporation)
       
Total Assets Total Liabilities

Net Worth


Name of Owners

Name and Title of Officers

% of Ownership


Are you an insurance agent?

Yes

No

Agent License #

Agent State

Completion of this form constitutes permission for Cal Society Insurance Services to obtain customer information which will be used to determine bonding eligibility. This information will be held in the strictest confidence.