Lost Securities Surety Bond Application

Lost Securities Application

20. Please complete the following balance sheet, or attach one to your submission.

Attach Balance Sheet (optional)

Drop a file here or click to upload Choose File

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Assets

Cash on hand (not in bank)

Cash in the following banks

Bank name

Dollar amount

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Other Securities (Market Value)

Government bonds

Security name

Dollar amount

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Accounts Receivable due in 60 days (dollar amount)

Accounts Receivable past due (dollar amount)

Notes Receivable (dollar amount)

Inventory (dollar amount)

Real Estate in my name

Property address

City

State

Zip code

Value of property

Description of property

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All other assets (describe including value)

Liabilities

Accounts Payable due in the next 60 days (dollar amount)

Accounts Payable past due (dollar amount)

Loans from Banks

Dollar amount

How secured

When due

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Notes Payable (not to banks)

Dollar amount

How secured

When due

Add Remove

Chattel Mortgages

Dollar amount

Describe mortgage

Add Remove

Mortgages on Real Estate

Bank

Dollar amount

Property description

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All other liabilities (describe including value)

Capital Stock paid in (if a corporation)

Surplus or net worth

The undersigned applicant (and indemnitors, if any) requests that Star Insurance Company (the “Company”) become surety for, and furnish such bond or bonds as may now or hereafter be required by or on behalf of the undersigned applicant (the indemnitors, if any, warranting that they have a substantial, material and beneficial interest in the affairs of the applicant and in the transactions in connection with which such bond(s) are required).

Any person who submits this application containing any materially false information or conceals information for the purpose of misleading the Company may be subject to criminal and civil penalties. The undersigned applicant (and indemnitors, if any) certifies that the statements made in this application, including any financial statements, are true and accurate. Statements on the application are made for the purpose of inducing the Company to execute such bond(s), and the undersigned applicant (and indemnitors, if any), in consideration of the Company issuing and executing such bond(s), jointly and severally covenant and agree to:

(a) Indemnify and save the Company harmless from and against all liability, claims, losses, costs, damages, suits, charges and expenses of whatsoever kind and nature, including reasonable attorney’s fees, which the Company shall at any time sustain or incur, because the Company has become the surety on any such bond(s), or any modification, renewal or continuation thereof, or new bond(s) substituted therefore.

(b) At the request of the Company, obtain the release and discharge of the Company from any further liability under said bond(s), and should the undersigned fail or refuse to do so, the Company shall have the right to proceed in any manner it may deem necessary to secure or attempt to secure its discharge, and the undersigned applicant (and indemnitors, if any) waive any and all claims against the Company for damages arising out of such proceedings and agree to reimburse the Company for all expenses, including reasonable attorneys’ fees, which the Company may incur.

I understand that clicking “Yes” below acts as my electronic signature and signifies my intent to sign the application and indemnity agreement. By clicking “Yes” below, I authorize the Meadowbrook Insurance Group and its affiliates to request my consumer credit report information for the purpose of evaluating my credit worthiness in connection with this bond application. I further consent to conduct transactions electronically with Meadowbrook Insurance Group and its affiliates. I understand that if I do not consent to conduct transactions electronically, a paper copy of these documents will be provided upon my request. *

Yes

Lost Securities Bond Application