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| Complete, Print & Fax
this Application with a copy of the first page of your most current tax returns, to (212) 425-2539. (Mail the original to the above address) ***Non-Agents / Brokers: Original application with payment must be received by our office before the bond can be issued. |
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| Name of Applicant (s) | Street Address of Place of Business | |
| Trade Name | City, State, Zip Code | |
| E-mail Address | County | |
INDICATE BY MARKING AN "X" IN THE
PROPER , THE DESCRIPTION
OF YOUR BUSINESS AS IT WILL APPEAR ON YOUR APPLICATION FOR A LICENSE.
| MANUFACTURER | PENAL AMT OF BOND | PREMIUM | |||
| 1 YEAR | 2 YEARS | 3 YEARS | |||
| Micro Brewer | $1,000.00 | $50.00 | |||
| Brewer | 15,000.00 | 180.00 | |||
| Distiller (Class A) | 25,000.00 | 300.00 | 525.00 | 750.00 | |
| Distiller (Class B) | 25,000.00 | 300.00 | 525.00 | 750.00 | |
| Distiller (Class B1) | 25.000.00 | 300.00 | 525.00 | 750.00 | |
| Distiller (Class C) | 5,000.00 | 60.00 | 105.00 | 150.00 | |
| Wineries | 10,000.00 | 120.00 | |||
| Cider Products and/or Sale | 1,000.00 | 50.00 | |||
| Farm Winery | 1,000.00 | 50.00 | |||
| WHOLESALER | PENAL AMT OF BOND | PREMIUM | |||
| 1 YEAR | 2 YEARS | 3 YEARS | |||
| Beer | $10,000.00 | $120.00 | |||
| Wine | 10,000.00 | 120.00 | |||
| Liquor | 20,000.00 | 240.00 | 420.00 | 600.00 | |
| VENDOR | 1,000.00 | 50.00 | 75.00 | 100.00 | |
| OFF-PREMISE | PENAL AMT OF BOND | PREMIUM | |||
| 1 YEAR | 2 YEARS | 3 YEARS | |||
| Beer (Grocery or Drug Store) | $1,000.00 | $50.00 | $75.00 | $100.00 | |
| Wine and Cider | 1,000.00 | 50.00 | |||
| Liquor (Liquor Store) | 1,000.00 | 50.00 | 75.00 | 100.00 | |
| Beer / Wine Products | 1,000.00 | 50.00 | 75.00 | 100.00 | |
| ON PREMISE | PENAL AMT OF BOND | PREMIUM | |||
| 1 YEAR | 2 YEARS | 3 YEARS | |||
| BEER | |||||
| Eating Place | $1,000.00 | $50.00 | $75.00 | $100.00 | |
| Ballpark or Racetrack | 1,000.00 | 50.00 | $75.00 | 100.00 | |
| Vessel | 1,000.00 | 50.00 | $75.00 | 100.00 | |
| Summer Only | 1,000.00 | 50.00 | |||
| Winter Only | 1,000.00 | 50.00 | |||
| WINE, BEER, AND CIDER | PENAL AMT OF BOND | PREMIUM | |||
| 1 YEAR | 2 YEARS | 3 YEARS | |||
| Club, Hotel or Restaurant | 1,000.00 | $50.00 | |||
| LIQUOR, WINE, AND BEER | PENAL AMT OF BOND | PREMIUM | |||
| 1 YEAR | 2 YEARS | 3 YEARS | |||
| Restaurant, Hotel, Club Tavern, Catering Establishment or Vessel | $1,000.00 | $50.00 | $75.00 | ||
| Restaurant Brewer | 2,000.00 | 100.00 | 150.00 | 200.00 | |
| Railroad Car | 1,000.00 | 50.00 | 75.00 | ||
| Summer Only | 1,000.00 | 50.00 | |||
| Winter Only | 1,000.00 | 50.00 | |||
| PERMITTEES | PENAL AMT OF BOND | PREMIUM | |||
| 1 YEAR | 2 YEARS | 3 YEARS | |||
| Bottling | $5,000.00 | $75.00 | $131.25 | $187.50 | |
| Broker | 1,000.00 | 50.00 | 75.00 | 100.00 | |
| Warehouse | 5,000.00 | 50.00 | 87.50 | 125.00 | |
| Trucking (No. of Trucks Operating Under Permit) |
1,000.00 | *50.00 | *75.00 | *100.00 | |
| *Add 60¢ for each truck in excess of three, max. $60.00 | |||||
| *2 yr. premium $75.00 + $1.05 for each truck in excess of three, max. $105.00 | |||||
| *3 yr. premium $100.00 + $1.50 for each truck in excess of three, max. $150.00 | |||||
| Fleet Trucking | 1,000.00 | 60.00 | |||
| SOLICITOR | 1,000.00 | 50.00 | 75.00 | 100.00 | |
| SOLICITOR PERMIT **(WRITE EMPLOYER'S NAME BELOW) | |||||
| ** FOR SOLICITOR BONDS ONLY | |
| EMPLOYER'S NAME: | |
| STREET ADDRESS: | |
| CITY AND COUNTY OF: | |
| PRODUCER INFORMATION: | |
| BROKER OR GENERAL AGENT: | |
| STREET ADDRESS: | |
| CITY, STATE, ZIP CODE: | |
| AGENT/BROKER'S LICENSE #: | |
| AGENT'S COMPANY: | |
| TELEPHONE NUMBER: | |
| E-MAIL ADDRESS: |
| 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. I, or we, personally, as well as an officer of the corporation, on behalf of the corporation or partnership, agree to pay the original premium and any subsequent or additional premium and agree to indemnify and keep indemnified the Company and save it harmless from and against any and all losses, demands, liabilities and expenses including attorney and counsel fees, which it shall at any time sustain or incur and will pay over, reimburse the Company, its successors and assigns, all sums and amounts of money which the Company or its representatives shall pay or cause to be paid, or become liable to pay under its obligations under said bond; or any charges or expense incurred in the investigation or in connection with any litigation by reason of the execution thereof; and will upon demand place the Company in funds with which to meet any such claim or expense, even though the Company or its representatives shall have paid, out such sum or any part thereof or not. |
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***NOTICE - IF CORPORATION -
THE APPLICATION MUST BE |
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(End of document)