Accredited Surety and Casualty Company, Inc.
P.O. Box 140855 · Orlando, FL 32814-0855
4798 New Broad Street · Suite 200 · Orlando, FL 32814
A Randall & Quilter Group Company

INDEMNITOR APPLICATION AND AGREEMENT

(Please answer each question in full. Please print answers)

THIS IS A 4 PAGE DOCUMENT - Read All Pages Carefully

You, the undersigned Indemnitor ("Indemnitor" or "you"), hereby represent and warrant that the following declarations made and answers given are true, complete and correct and are made for the purpose of inducing Accredited Surety and Casualty Company, Inc. ("Surety") to issue, or cause to be issued, bail bond(s) or undertaking(s) for you (singularly or collectively the "Bond") for

("Defendant") using power of attorney number(s) (if known)
, in the total amount of
Dollars
($
) in the
court of
1. INDEMNITORS NAME AND ADDRESS
Name
Nickname/Alias
First
Middle
Last
.
Home Phone
cell Phone
work Phone
email:
current home address
how long rent or own     landlord
phone
former home address
how long rent or own     landlord
phone
2. PERSONAL DESCRIPTION
date of birth
where born
sex male female     race
social security #
driver's license #
issuing state
How Long in U.S.
U.S. citizen Yes No nationality
alien#
union
local#
military service branch
active yes no     discharge date
additional notes
3. EMPLOYMENT
Occupation
employer
work phone
how long
employer address
supervisor's name
4. MARITAL STATUS/CHILDREN
married divorced seperated widowed single cohab
Spouse/Girl/Boyfriend's Name
First
Middle
Last
How Long Married/Together
Address (if different)
email:
social security #
Home Phone (if different)
cell phone
Occupation
employer
how long
employer name
5. AUTOMOBILE
year
make
model
color
plate#
state
where financed
amount owed $
6. REFERENCES
name
relation
address
employer
home phone
work phone
cell phone
name
relation
address
employer
home phone
work phone
cell phone
name
relation
address
employer
home phone
work phone
cell phone
7. FINANCIAL STATEMENT/CREDIT INFORMATION
cash on hand$
cash in bank$
real estate value$
real estate mortgage$
In Whose Name Is Title
Monthly Salary Or Wages $

Bail Producer [Include: name, address, phone no. and license no.]

FLORIDA RESIDENTS Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree





I agree to the terms set forth on all 4 pages of this agreement.

Signed, Sealed And Delivered at
month
day of
year

WITNESS

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print

INDEMNITOR
By typing my name below, I am electronically signing this application & agreement.

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Indemnity Agreement Terms

Before signing, please read the terms of the Indemnity Agreement: