|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| |
|
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
|
|
|
$1,000.00
|
$50.00
|
|
|
|
|
15,000.00
|
180.00
|
|
|
|
|
25,000.00
|
300.00
|
525.00
|
750.00
|
|
|
25,000.00
|
300.00
|
525.00
|
750.00
|
|
|
25.000.00
|
300.00
|
525.00
|
750.00
|
|
|
5,000.00
|
60.00
|
105.00
|
150.00
|
|
|
10,000.00
|
120.00
|
|
|
|
|
1,000.00
|
50.00
|
|
|
|
|
1,000.00
|
50.00
|
|
|
|
| |
|
WHOLESALER
|
PENAL AMT OF BOND
|
PREMIUM
|
| |
|
|
1 YEAR
|
2 YEARS
|
3 YEARS
|
|
|
$10,000.00
|
$120.00
|
|
|
|
|
10,000.00
|
120.00
|
|
|
|
|
20,000.00
|
240.00
|
420.00
|
600.00
|
| |
|
|
1,000.00
|
50.00
|
75.00
|
100.00
|
|
| |
|
OFF-PREMISE
|
PENAL AMT OF BOND
|
PREMIUM
|
| |
|
|
1 YEAR
|
2 YEARS
|
3 YEARS
|
|
|
$1,000.00
|
$50.00
|
$75.00
|
$100.00
|
|
|
1,000.00
|
50.00
|
|
|
|
|
1,000.00
|
50.00
|
75.00
|
100.00
|
|
|
1,000.00
|
50.00
|
75.00
|
100.00
|
|
| |
|
ON PREMISE
|
PENAL AMT OF BOND
|
PREMIUM
|
| |
|
|
1 YEAR
|
2 YEARS
|
3 YEARS
|
| BEER |
|
|
$1,000.00
|
$50.00
|
$75.00
|
$100.00
|
|
|
1,000.00
|
50.00
|
75.00
|
100.00
|
|
|
1,000.00
|
50.00
|
75.00
|
100.00
|
|
|
1,000.00
|
50.00
|
|
|
|
|
1,000.00
|
50.00
|
|
|
|
| |
|
WINE, BEER, AND CIDER
|
PENAL AMT OF BOND
|
PREMIUM
|
| |
|
|
1 YEAR
|
2 YEARS
|
3 YEARS
|
|
|
$1,000.00
|
$50.00
|
$75.00
|
|
|
| |
|
LIQUOR, WINE, AND BEER
|
PENAL AMT OF BOND
|
PREMIUM
|
| |
|
|
1 YEAR
|
2 YEARS
|
3 YEARS
|
|
|
$1,000.00
|
$50.00
|
$75.00
|
|
|
|
2,000.00
|
100.00
|
150.00
|
200.00
|
|
|
1,000.00
|
50.00
|
75.00
|
|
|
|
1,000.00
|
50.00
|
|
|
|
|
1,000.00
|
50.00
|
|
|
|
| |
|
PERMITTEES
|
PENAL AMT OF BOND
|
PREMIUM
|
| |
|
|
1 YEAR
|
2 YEARS
|
3 YEARS
|
|
|
$5,000.00
|
$75.00
|
$131.25
|
$187.50
|
|
|
1,000.00
|
50.00
|
75.00
|
100.00
|
|
|
5,000.00
|
50.00
|
87.50
|
125.00
|
|
|
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 |
|
|
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
|
|
|
| |
|
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.
|
| |
| |
|
|
| |
|
(Name of Corporation)
|
| |
| BY |
___________________________________
|
| |
Officer
|
|
| |
***NOTICE - IF CORPORATION - THE APPLICATION MUST BE
SIGNED BY LICENSEE AS APPLICANT/PERSONAL GUARANTOR AND CORPORATION.
ALL APPLICATIONS ARE TO BE SIGNED AND RETURNED WITHIN TEN (10) DAYS.
|
