GENERAL APPLICATION FOR STATUTORY,

BLANKET CLIENT & CLIENT CONTRACT BONDS

Underwritten by Travelers Casualty and Surety Company of America

_______________________________________________________________
Name and title of person submitting bond request
ACA Group Insurance and Bond Programs
ACA RISK MANAGEMENT DEPARTMENT

(*INCOMPLETE APPLICATIONS NOT ACCEPTED*)

Name of Company as It Should Appear on Bond:_____________________________________________________________________________

______________________________________________________________________________________________________________________
Street Address:_______________________________________ City: __________________ County: ______________State: ______ Zip: _________
Mailing Address: _________________________________________________ City: __________________State: _________ Zip:_________
Phone: _______________ Ext: _________ Fax:_________________Contact:_____________________Email:________________________________
Ownership:

Individual

Partnership

Corporation

Other_____________

ACA Member #: _____________________

(Required)

UNDERWRITING INFORMATION
Fiscal Year End Date: ________________ Tax ID: ___________________________
Year Agency Established: __________________ Year Current Ownership Purchased Agency:___________ State of Incorporation: _______________

List of Corporate Officers, Stockholders, Partners or Proprietors (Attach additional page if necessary)
Full Legal Name and
Home Address

Age

Social Security No.

Position

% Ownership
of Applicant

Spouses Name

List of Parent Companies, Affiliated, Subsidiary or Related Companies where Applicant or its Stockholders have an interest
Company Name and
Company Address

Relationship and
Percentage of Ownership

Scope of Operations

Has your firm or any of its principals ever petitioned for bankruptcy or failed in business?

No

Yes (If yes, attach complete explanation)

Have you ever had a business or state license suspended, revoked or denied?

No

Yes (If yes, attach complete explanation)

Have you ever been a party to a surety bond claim in the past or present?

No

Yes (If yes, attach complete explanation)

Does anyone have knowledge of any judgments or outstanding suits?

No

Yes (If yes, attach complete explanation)

CURRENT / PRIOR BOND HISTORY

Current Surety Company:

ACA International

Other If Other, Surety Company Name: ______________________ Total Bond Amount: ______

Prior Surety Company Name (print N/A if not applicable): _______________________________ Reason for leaving: ___________________________
________________________________________________________________________________________________________________________

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1 . Statutory Bond(s) Requested (Bonds cannot be back-dated)

State

Bond Limit

Effective Date

State

Bond Limit

Alaska

$5,000

New Jersey

$5,000

Arizona
(10K 35K)
Arkansas
(10K 25K)
Colorado
(12K 20K)
Connecticut

New Mexico
(5K - 25K)
City of Buffalo, NY

New York City, NY

(Child Support Bond)
North Carolina
(10K - 75K)

$
$25,000

Effective Date

$5,000
$5,000
$
(If Non-Resident
of NC add 10K)
$20,000

Florida
(Commercial Only)
Hawaii

$50,000

North Dakota

$25,000

Idaho
(15K 100K)

Illinois

$25,000

Indiana

$5,000

Oregon
(10K 15K)
Pennsylvania
Collector /Repo.
Sales Finance
Tennessee
(15K 25K)
Texas

Maine
(20K 50K)
Maryland

$50,000

$5,000

Texas
(Child Support Bond)
Utah

Massachusetts

$25,000

Washington

$5,000

Michigan
(5K - 50K)
Minnesota
(50K 100K)
Nebraska
(5K 15K)
Nevada
(35K - 60K)

West Virginia

$5,000

Wisconsin
(25K +)
Wyoming

$10,000

Other :

$5,000

$
$10,000

$10,000

(DATE LICENSE APPROVED)

WA - Indicate address of WA In-state location if applicable:

________________________________________________________________________________________________

2. Blanket Client Bond Limit Requested (Will not fulfill state licensing requirements)
Limit of Bond Desired:

$10,000

$25,000

$50,000

Other $ ___________________________

Effective Date Desired: _______________________________

3. Client Contract Bond Requested

Name of Client: ____________________________________________________________________________________________________________
Address of Client: __________________________________________________________________________________________________________
Limit of Bond Desired:

$5,000

$10,000

$25,000

$50,000

Other $______________

Effective Date Desired: _______________________________ (A copy of the contract must be included with the application.)
Return to:

ACA International, Risk Management Department, Bond Unit

P. O. Box 390106,
Minneapolis, MN 55439-0106
Phone 952-928-8000 Fax 952-928-3837

NOTES:

Financial information will be requested once the total bond aggregate reaches more than $250,000. However, the bonding company
reserves the right to request financial information at any time regardless of total bond aggregate.

Rev. 7/12
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