Small Contract Account Questionnaire

Home Office: Columbus, Ohio
Surety Administrative Office:
7 World Trade Center, 37th Floor
250 Greenwich Street
New York, NY 10007-0033
1-888-800-0147 • Fax (480) 905-5454

SMALL CONTRACT ACCOUNT QUESTIONNAIRE

Please complete this questionnaire in its entirety for single projects up to $350,000 and aggregate bond lines up to $500,000.Individual Credit Reports will be run on all business owners and spouses; therefore please be sure to include spousal information,if applicable, making sure that each and every individual signs the credit consent form.Please attach the following to your submission:

•Any supporting information with regards to the company or the specific job request

•Most recent Corporate Tax Return

•Current Personal Financial Statement

Once the forms have been completed and submitted to Nationwide Mutual Insurance Company,an underwriter will review your file.The underwriter may require additional information in order to support the requested bond.Corporate, Cross-Corporate, Personal and Spousal indemnity will be required on all submissions made to Nationwide Mutual Insurance Company.

COMPANY INFORMATION

Company Name:Federal Tax ID No.:

Address: Date Company Started:

City: State: Zip: Corporate Cash Balance:

Phone: Average Cash Balance:

Previous Surety Company: Bank Line of Credit Amount:

Reason for Leaving Prior Surety: Bank Line Outstanding:

Type of Work Performed:

Largest Job Completed To Date:

1.Do owner(s) have interests in other construction businesses?...... Yes No

2.Have you ever failed to complete a project?...... Yes No

3.Are you in litigation for any current or previous work?...... Yes No

4.Do you currently have any unfinished bonded contracts?...... Yes No

5.Has the contractor ever filed for corporate bankruptcy?...... Yes No

6.Has the contractor been in business for less than twelve (12) months?...... Yes No

For questions 1.-6.above, please provide details for any “Yes” answers.

COMPANY OWNERSHIP INFORMATION

PROJECT SPECIFIC INFORMATION

If this is a final bond, what is the contract price?

What is the bond amount, if different from the contract price?

If this is a bid what is the estimated Bid Amount?

What is the bid Percentage Requirement?

Bid Results(Name & Amount):1st

2nd

3rd

Is the Project within one hundred fifty (150) miles of the Company’s office?...... Yes No

What is the estimated number of days for completion?

What are the per day Liquidated Damages?

How long is the Maintenance period?

How much of the work will be subcontracted out?...... %

List any Subcontractors and their portion of work:

Are thereobligee specific bond forms required?...... Yes No

(If “Yes,” please provide a copy for review)

FRAUD PREVENTION—WARNING

NOTICE TO APPLICANTS:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL PENALTIES.

NOTICE TO ARKANSAS, NEW MEXICO AND WEST VIRGINIA APPLICANTS:ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT, OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO COLORADO APPLICANTS:IT IS UNLAWFUL TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING FACTS OR
INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE COMPANY.PENALTIES MAY INCLUDE IMPRISONMENT, FINES, DENIAL OF INSURANCE AND CIVIL DAMAGES.ANY INSURANCE COMPANY OR AGENT OF AN INSURANCE COMPANY WHO KNOWINGLY PROVIDES FALSE, INCOMPLETE OR MISLEADING FACTS OR INFORMATION TO A POLICY HOLDER OR CLAIMANT FOR THE PURPOSE OF DEFRAUDING OR ATTEMPTING TO DEFRAUD THE POLICYHOLDER OR CLAIMANT WITH REGARD TO A SETTLEMENT OR AWARD PAYABLE FROM INSURANCE PROCEEDS SHALL BE REPORTED TO THE COLORADO DIVISION OF INSURANCE WITHIN THE DEPARTMENT OF REGULATORY AUTHORITIES.

NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:WARNING:IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR AN OTHER PRISON, PENALTIES INCLUDE IMPRISONMENT AND/OR FINES.IN ADDITION, AN INSURER MAY DENY INSURANCE BENEFITS IF FALSE INFORMATION MATERIALLY RELATED TO A CLAIM WAS PROVIDED BY THE APPLICANT.

NOTICE TO FLORIDA APPLICANTS: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.

NOTICE TO KANSAS APPLICANTS:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY, WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.

NOTICE TO KENTUCKY APPLICANTS:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON, FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT, MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, SUBJECT TO CRIMINAL PROSECUTION AND CIVIL PENALTIES.

NOTICE TO LOUISIANA APPLICANTS:ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO MARYLAND APPLICANTS:ANY PERSON WHO KNOWINGLY OR WILLFULLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN PRISON.

NOTICE TO MAINE APPLICANTS:IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN
INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY.PENALTIES MAY INCLUDE IMPRISONMENT, FINES OR A DENIAL OF INSURANCE BENEFITS.

NOTICE TO MINNESOTA APPLICANTS:A PERSON WHO FILES A CLAIM WITH INTENT TO DEFRAUD OR HELPS COMMIT A FRAUD AGAINST AN INSURER IS GUILTY OF A CRIME.

NOTICE TO NEW JERSEY APPLICANTS:ANY PERSON WHO INCLUDES ANY FALSE AND MISLEADING INFORMATION ON AN APPLICATION FOR AN INSURANCE POLICY IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.

NOTICE TO OHIO APPLICANTS:ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

NOTICE TO OKLAHOMA APPLICANTS—WARNING:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY (365:15-10, 36 §3613.1).

NOTICE TO OREGON APPLICANTS:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURER, MAKES ANY MISSTATEMENT, MISREPRESENTATION, OMISSION OR CONCEALMENT MAY BE GUILTY OF INSURANCE FRAUD.FURTHERMORE, THE IN-SURER MAY ASSERT A RIGHT TO REMEDY IF THE MISSTATEMENT, MISREPRESENTATION, OMISSION OR CONCEALMENT IS FRAUDULENT OR MATERIAL TO THE INTERESTS OF THE INSURER.FURTHERMORE, THE INSURER MAY DENY A CLAIM IF THE INSURER SHOWS THAT THE MISINFORMATION IS MATERIAL TO THE CONTENT OF THE POLICY, THE INSURER RELIED UPON THE MISINFORMATION AND THAT THE INFORMATION WAS EITHER MATERIAL TO THE RISK ASSUMED BY THE INSURER OR THAT THE MISINFORMATION WAS PROVIDED FRAUDULENTLY.

NOTICE TO PENNSYLVANIA APPLICANTS:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON, FILES A STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT, MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, SUBJECT TO CRIMINAL PROSECUTION AND CIVIL PENALTIES.

NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS:IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY.PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

NOTICE TO VERMONT APPLICANTS:ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.

NOTICE TO NEW YORK APPLICANTS:ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

NOTICE OF INTENT TO REVIEW CONSUMER CREDIT INFORMATION

You have represented that you have an interest in(Company Name)

obtaining one or more bonds from Nationwide Mutual Insurance Company (“NMIC”).NMIC requires a review of your credit history before it makes a decision on whether to issue such a bond.In order to obtain such credit information, NMIC is requesting your consent to do so.You will be notified if NMIC declines to issue such bond if the reason for the declination is based completely or in part on the information contained in such report.Included with such notice will be the source of the report including addresses, phone numbers and instructions on how you can get a copy of your report so you can check it for accuracy.

CONSENT TO OBTAIN CONSUMER CREDIT REPORT

I, the undersigned, hereby consent to NMIC obtaining a Consumer Report as defined under the Fair Credit Reporting Act which report will include information by a consumer reporting agency bearing on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. I agree that a photocopy or facsimile of this agreement shall constitute a written instruction which NMIC may present to a Consumer Credit Reporting Agency as proof of NMIC’s authority to obtain such credit information.

Signature of Person Granting Consent:Signature of Person Granting Consent:

(Printed Name of Person Granting Consent)(Printed Name of Person Granting Consent)

Date: Date:

Social Security Number: Social Security Number:

Signature of Person Granting Consent:Signature of Person Granting Consent:

(Printed Name of Person Granting Consent)(Printed Name of Person Granting Consent)

Date: Date:

Social Security Number: Social Security Number:

Signature of Person Granting Consent:Signature of Person Granting Consent:

(Printed Name of Person Granting Consent)(Printed Name of Person Granting Consent)

Date:Date:

Social Security Number:Social Security Number:

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