PRELIMINARY APPLICATION /
In CA, DBA: Griffin Insurance Services, CA License #0G66558
800.562.8095 Phone . 425.453.8696 Fax
PO Box 3867 . Bellevue, WA 98009 /
Bellevue. Portland. Spokane.
Please type or complete with a BLACK pen. Thank you!
Agency: / Contact:Contact by: / Fax E-Mail
UNDERWRITING DETAIL
Business Name:* / Phone #: / --
BusinessAddress:*
Form of Business:* / Individual Partnership Corporation LLC / State Required:
Type of Bond: / Click for options, or type here:SpecialtyElectricalGeneralOR: Res. GeneralOR: Res. SpecialtyOR: Res. Limited-RLCOR: Res. Developer-RDOR: Comm'l General-2OR: Comm'l Specialty-2OR: Comm'l Dev.-CDOR: Comm'l Specialty-1 / Bond Amount:
Owner Name: / Date of Birth:
Social Security: / --
First / Last / Middle
Home Address:
Single
Married / Divorced
Widowed / Spouse’s Information: / Date of Birth:
Social Security: / --
First / Last / Middle
How many years has this business been licensed and bonded? / How many years experience in related field?
Do you own real estate? No Yes / UBI#:
Has Applicant moved within the last 6 months? No Yes
Has Applicant filed Bankruptcy in the last 10 years? No Yes; Explain:
Have you ever been an owner or an Indemnitor on business that has had a bond claim? No Yes
Add’l Owners? / YES - please repeat form No / Percentage of Ownership:
*Please note that if applicant is in WA and new in business, state guidelines require that the Individual’s name(s)(as it appears in the Business Name before the DBA, if applicable) MUST exactly match the individual’s name as it appears onhis/her driver’s license.
MARKET SELECTIONMy client has already been denied coverage by the following markets:
Please qualify my Applicant with the following Market Only / ***HCC SuretySafeco CompaniesFrontier BondingGreat American Ins.
Please qualify my Applicant for the best valued/pricing option using all accessible markets.
My client best describes their credit history as follows:
Great – Excellent Credit / Good – Great Credit / Poor – OK Credit / Adverse or No Credit
GUS CREDIT CHECK DISCLAIMER
I have discussed the Underwriting Process with my Client. My client is aware that his/her personal Credit History will be part of the underwriting process. We also understand that all Owners of a Partnership, LLC and/or Corporation (even silent members/shareholders) will be subject to approval and have been provided for underwriting review. By providing the personal information above, my client has provided GUS his/her consent to begin the Underwriting Process. GUS is not provided a copy of the personal credit report nor able to discuss any item(s) that may appear on the applicant’s report. All Underwriting decisions are provide by the qualifying Carrier and are final. All inquires about an individual’s personal credit history should be made directly to the Credit Reporting Companies themselves.
*Certain markets require the applicant’s signed consent in order X______
to obtain credit information. We can proceed without the signature, Applicant’s Signature*
but we will not be able to obtain quotes from all possible markets.
GUS-BOND-2 (10/11)