FINANCIAL CASUALTY & SURETY, INC

Transcription

1 FINANCIAL CASUALTY & SURETY, INC The Bail Insurance Company 3131 Eastside St. Suite 600 Houston, Texas P.O. Box 4479 Houston, Texas Toll Free: Fax: fcs APPLICATION FOR NON-LIABLE BAIL AGENT Notice to Applicant: FEDERAL LAW VIOLENT CRIME CONTROL AND LAW ENFORCEMENT ACT OF 1994, 18 U.S.C. SECTION 1033 prohibits certain activities by or affecting persons engaged, or proposing to become engaged, in the business of insurance: (e)(1)(a) (B) (e)(2) Any individual who has been convicted of any criminal felony involving dishonesty or a breach of trust, or who has been convicted of an offense under this section, and who willfully engages in the business of insurance whose activities affect interstate commerce or participates in such business, shall be fined as provided in this title or imprisoned not more than 5 years, or both. Any individual who is engaged in the business of insurance whose activities affect interstate commerce and who willfully permit the participation described in subparagraph (A) shall be fined as provided in this title or imprisoned not more than 5 years, or both: A person described in paragraph (1)(A) may engage in business of insurance or participate in such business if such person has the written consent of any regulatory official authorized to regulate the insurer, which consent specifically refers to 18 U.S.C. Sections 1033 and You must answer every question on the Application. If a question does not apply, indicate N/A in the space provided for the answer. Your answers are not limited to the space provided on the Application. Attach additional pages as needed. Financial Casualty & Surety, Inc will not process incomplete Applications. Additional information may be requested. (PLEASE TYPE OR PRINT ALL INFORMATION ON THIS APPLICATION) EMPLOYER INFORMATION Agency/Employer Name Agency Owner Name Agency Phone # Agency Address Agency Address SECTION I APPLICANT INFORMATION Applicant Name Applicant Home Address # & Street City County State Zip Page 1 of 3 FCS Non-Liable AgentApp tapplication 07-05

2 Date of Birth Place of Birth U.S. Citizen (yes) (no) Social Security # Name of Spouse Home Phone # Cell Phone # Do you have a current in-force bail bond license: (yes) (no) License # License expiration date (Attach a copy of current license) How long have you been licensed? What states are you currently licensed in? What states have you been licensed in? List all Insurance Companies and Agents/General Agents that you have issued bail bonds for and/or been appointed with: Dates: From/To Insurance Company or Agent/General Agent Name: Are you engaged in any other business or occupation? (yes) (no) If yes, Nature of business: Name & Address of Business: How long? Owner s Name: Have you ever-declared bankruptcy: (yes) (no) (If yes, attach an explanation.) SECTION II APPLICANT EDUCATION Highest level of education achieved: High School; Associate; Bachelors; Advanced. Major: Name of Institution: Date Graduated: FCS Non-Liable AgentApp tapplication Page 2 of 3

3 SECTION III APPLICANT CRIMINAL AND REGULATORY HISTORY Have any disciplinary actions ever been taken by any regulatory agency against you, your business or any business with which you have been directly connected? (yes) (no) (If yes, attach a full explanation.) Have you ever had your bail contract cancelled by a surety or general agent? (yes) (no) (If yes, please attach specific information surety name, reasons, when, etcetera.) Have you ever been arrested, charged, convicted of or pled nolo conterdere (no contest) to a felony, gross misdemeanor or a misdemeanor involving moral turpitude or currently have pending any misdemeanor or felony charges against you? (Misdemeanor does not mean minor traffic violations.) (yes) (no) (If yes, please attach detail explanation giving dates, names and address of courts, basis of charges, outcomes and whether you received an executive pardon.) RE: TITLE 28 PRIVACY ACT, FREEDOM OF INFORMATION ACT, TITLE 6 FAIR CREDIT REPORTING PUBLIC LAW I understand that investigative inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. I also understand that you will be requesting information from various federal, state and other agencies which maintain records concerning any past activities relating to my credit, criminal, civil and other experiences as well as claims involving me in the field of insurance. I authorize, without reservation, any party or agency contacted to furnish the above-mentioned information about me to you. I have a right to make a written request within a reasonable period of time to receive additional information about the nature and scope of this investigation. I hereby consent to your obtaining the above information and agree that, if appointed with you, such information you obtain along with information relating to my performance with you will be accessible through you by future insurance companies to which I might apply. I certify that each statement therein made is full, true and correct to the best of my knowledge. I agree that pursuant to the Violent Crime Control and Law Enforcement Act of 1994, 18 United States Code Sections 1033, 1034, I will notify Financial Casualty & Surety, Inc, in writing, within 30 days of my being convicted of a felony. APPLICANT SIGNATURE DATE SIGNED FCS Non-Liable AgentApp tapplication Page 3 of 3

4 APPOINTED AGENT PRODUCER INDEMNIFICATION AGREEMENT THIS AGREEMENT is made and entered into this day of 20, by and between FINANCIAL CASUALTY & SURETY, INC., a Texas Corporation (hereinafter Company ), and Global Surety Services, Inc. and/or Milton Tillman, III (hereinafter Producer ) and hereinafter Appointed Agent ) WHEREAS, Producer(s) desires to have Company appoint hereinafter referred to as Appointed Agent. WHEREAS, Appointed Agent desires to be appointed to write bail for Company and Liable Producer(s). THIS AGREEMENT will not become effective until the Appointed Agent is legally licensed, appointed and authorized to conduct business in the State of NORTH CAROLINA. WHEREAS, it is the intent of the parties to this Agreement that Appointed Agent shall and does hereby agree to indemnify Company and Producer(s) from any and all claims or losses of any kind or nature, whatsoever, arising out of or related to Appointed Agent s actions as stated in this Agreement. NOTWITHSTANDING any language to the contrary in this Agreement or any other Agreement, Appointed Agent is fully personally responsible, legally and financially, for and has a fiduciary responsibility to Company, Producer(s) for any of Appointed Agent s negligent actions, any and all Company Powers of Attorney given to the Appointed Agent s possession, any and all premium and fees received by Appointed Agent and any and all collateral received by Appointed Agent or any person(s) acting for Appointed Agent until such unused or executed Powers and such premium, fees and collateral are given to Producer. NOTWITHSTANDING any language to the contrary in this Agreement or any other Agreement, Appointed Agent is fully personally responsible, legally and financially, for and has a fiduciary responsibility to Company, Producer for maintaining a valid bail license and for knowing, understanding and fully complying with all relevant federal, state and local laws, rules and regulations. FORMS. Appointed Agent agrees that only Company-approved forms will be used when transacting Company business. Where required by regulation or statute, Appointed Agent will only use or cause to be used Company-approved forms that have been filed with and approved by the respective state Department of Insurance. COMPANY may at its sole discretion settle any claims and such settlement shall be conclusively deemed to be in the best interest of Company, Producer, and Appointed Agent. FAILURES TO DECLARE BREACH NOT A WAIVER. The failure of Company to terminate or declare a breach of this Agreement on a particular occasion when such action is allowed hereunder shall not be construed, interpreted, or pleaded as either an express or implied waiver of the right to do so at a later date, nor shall it be deemed an express or implied waiver of any right of obligation

5 hereunder. To the maximum extent possible, Producer and Appointed Agent hereby waive any and all statutes of limitation otherwise applicable to Company s enforcement of its rights. APPLICABLE LAW, VENUE, AND FORUM. The parties hereto do hereby consent and stipulate to the jurisdiction of the courts of the State of Texas, County of Harris, where Company is based, for any action brought under this Agreement. ATTORNEY'S FEES. Should any litigation arise between the parties hereto related to this Agreement, the prevailing party shall be entitled to recover reasonable attorney's fees and other costs in addition to any other relief granted. SEVERABILITY AND GRAMMATICAL CONSTRUCTION. If any provision or item of this Agreement or the application form is held invalid, such invalidity shall not affect other provisions, items, or applications of this Agreement which can be given effect without the invalid provisions, items or applications, and to this end the provisions of this Agreement are hereby declared severable. Any word wherever used in this Agreement, either severally or conjunctively, shall be construed in the plural where the equitable interpretation of Agreement so requires, and the necessary grammatical changes to make the provisions hereof apply either in the singular or in the plural shall, in all cases, be assumed as though in each case fully expressed. IN WITNESS WHEREOF, the parties hereto have caused this Agreement to be executed in multiple parts. Financial Casualty & Surety, Inc. COMPANY L.S. Robert Sabo, Senior Vice President Initials APPOINTED AGENT L.S. Initials State of County of On before me, the undersigned, a Notary Public in and for said County and State, personally appeared known to me to be the person(s) whose name(s) is (are) subscribed to the within instrument and acknowledge that they executed the same. Witness my hand and official seal. Notary

6 PRODUCER Initials Milton Tillman, III L.S. State of Maryland County of On before me, the undersigned, a Notary Public in and for said County and State, personally appeared Milton Tillman, III known to me to be the person(s) whose name(s) is (are) subscribed to the within instrument and acknowledge that they executed the same. Witness my hand and official seal. Notary

7 NORTH CAROLINA DEPARTMENT OF INSURANCE APPOINTMENT OF SURETY BONDSMAN SEND TO: NCDOI/PEARSON VUE PO Box Raleigh, NC NAME OF INSURANCE COMPANY SURETY BONDSMAN APPOINTEE INFORMATION: Social Security Number Last Name First Middle Residence Street Address Mailing Address (if different from above) Date of Birth Name of Managing General Agent Street Address of Managing General Agent Mailing address( if different from above) City State Zip Code County City State Zip Code Surety Bondsman Address Home Telephone ( ) Managing General Agent Address Bus. Phone ( ) Surety Bondsman Appointee NCDOI Permit # Principal County where license registered Name of Supervising Bail Bondsman Supervising Bail Bondsman NCDOI Permit # Supervising Bail Bondsman Address The official signing below certifies the following: ATTESTATION BY INSURANCE COMPANY that the company has performed due diligence by performing background checks to verify appointee is trustworthy and financially responsible and meets all surety bondsman licensure qualifications of the North Carolina General Statutes; that our company shall cancel this surety bondsman s appointment with our company immediately if we are notified by a former insurer that this bondsman has failed to satisfy forfeitures and judgments, in a timely manner, on bonds written through their company; that the company will give its power of attorney to the surety bondsman appointed herein to execute or countersign bail bonds for such insurer; that the appointee has certified to the company that he/she is currently licensed as a surety bondsman in the State of North Carolina and is therefore exempt from initial licensing requirements; that the company is hereby requesting the Department of Insurance to register the appointee as a surety bondsman for said company and is affixing the corporate seal. (Corporate Seal) Signature of Company Official Effective Date of Appointment Company Name Date Signed SBB-APPT PV (11/2012)

8 AFFIDAVIT OF SURETY BONDSMAN REGARDING APPOINTMENT NCDOI/PEARSON VUE PO Box Raleigh, NC The General Assembly of North Carolina amended Article 71 of Chapter 58 of the General Statutes by adding a new section, effective October 1, N.C.G.S (a) states: (a) Before receiving an appointment, a surety bondsman shall submit to the Commissioner an affidavit, signed under oath, by the surety bondsman and by any former insurer, stating that the surety bondsman does not owe any premium or unsatisfied judgment to any insurer and that the bondsman agrees to discharge all outstanding forfeitures and judgments on bonds previously written. The affidavit shall be in a form prescribed by the Commissioner and shall be submitted by the surety bondsman to the former insurer. If the surety bondsman does not satisfy or discharge all forfeitures or judgments, the former insurer shall submit a notice, with supporting documents, to the appointing insurer, the surety bondsman, and the Commissioner, which states, under oath, that the surety bondsman has failed to satisfy, in a timely manner, the forfeitures and judgments on bonds written by the surety bondsman and that the former insurer has satisfied the forfeiture or judgment from its own funds. The former insurer shall submit the notice and supporting documents to the appointing insurer, the surety bondsman, and the Commissioner within 30 days after the former insurer receives the affidavit from the surety bondsman. Upon receipt of the notice and supporting documents, the appointing insurer shall immediately cancel the surety bondsman's appointment. The surety bondsman may be reappointed only upon certification by the former insurer that all forfeitures and judgments on bonds written by the surety bondsman have been discharged. The appointing insurer or surety bondsman may, within 10 days after receiving the notice and supporting documents from the former insurer, appeal to the Commissioner. Pursuant to this statute, surety bondsmen must complete the affidavit below. Surety Bondsman must provide a copy to all former appointing insurers and NCDOI; please list all former appointing insurers in the space below. Please select the appropriate option below and complete the information for the option selected. Option One: I,, surety bondsman, being fully duly sworn shows unto the Commissioner that I do not owe any premium or unsatisfied judgment to ANY, former insurer, as of (today s date). Furthermore, I agree to discharge all outstanding forfeitures and judgments on bonds previously written. Option Two: I,, surety bondsman, being first duly sworn shows unto the Commissioner that, due to a bankruptcy discharge, I do not owe any premium or unsatisfied judgment to ANY, former insurer, as of (today s date). Furthermore, I agree to discharge all outstanding forfeitures and judgments on bonds previously written that were not discharged in my bankruptcy proceeding. I am currently pursuing a surety bondsman appointment with appointing insurer. LIST OF FORMER APPOINTING INSURERS: (Attach additional sheets if needed) This is the day of, 20. Surety Bondsman Signature Sworn to and subscribed for me this day of, 20. Notary Public Signature My commission expires:, 20 Insurers: Print the appropriate form, either AFFIDAVIT BY FORMER INSURER or NOTICE UNDER OATH BY FORMER INSURER at complete and forward to NCDOI/Pearson Vue at the address at the top of the form.

9 FINANCIAL CASUALTY & SURETY 3131 Eastside #600 Houston TX ~~~ PO Box 4479 Houston TX (fax) (toll free) fcs BUF Account Set-up Requirements Fill out the following information so that your BUF account can be set-up to your desired specifications. Agent Number (not required): Agent Name Name requested to open Account/Statement (if different from above): Date: Address to send bank Statement: Social Security Number (enter to open account under personal name): or (enter only one number) Federal Tax ID (enter to open account under Business name): Initial deposit of $ (minimum $5,000.00) Included Yes No Make checks payable to name requested to open the account. Attach completed and signed W-9 Form with a legible copy of your driver s license. I fully understand this BUF account is open in accordance with my Bail Bond Agreement between agent and Financial Casualty & Surety, Inc. This BUF account will be opened using my SS# or Federal Tax ID #. Agent, as owner of the account, will pay all taxes due and payable with respect to income with this account. Financial Casualty & Surety, as the trustee and signer on the account, is the sole authority to withdraw funds or close the account. Signature Signature (09) BUFset-up_form (fcs - acc't understanding).doc