paymentbond

Contract Bonding Form

Performance Bond • Payment Bond • Maintenance Bond • Supply Bond • Construction Bond • Penalty Amount $400,000

Call 800-921-1008 with any questions

Bond Type

Single Bonds or Aggregate Programs up to $350,000 Aggregate Programs in excess of $350,000 up to $700,000

Contractor Data

Type of business

Company Name (Legal Name)

Phone Number

Email

Company Address

State

Type of Work

Date Started in Business

mm/dd/yy

If Incorporated, Incorporation Date

mm/dd/yy

State of Incorporation

Subsidiaries or Affiliates

Has the applicant been in claim, and/or denied bonding by another surety?

Yes No

(If yes, please explain)

Owner Data / Indemnitors

Provide the information below on all owners.

Bernard Fleischer & Sons may obtain a credit report about the applicant including its Owner(s) and Owner’s spouses in order to confirm the information provided in this application and obtain information about Applicant’s credit history.

Name

Phone Number

Address

State

Social Security Number

Date of Birth

mm/dd/yy

% of Business Ownership

Title or Position

Married?

Yes No

Spouse Name

Social Security Number

Date of Birth

mm/dd/yy

Is there an Additional Owner?

Yes No

Owner #2 Data

Name

Phone Number

Address

State

Social Security Number

Date of Birth

mm/dd/yy

% of Business Ownership

Title or Position

Married?

Yes No

Spouse Name

Social Security Number

Date of Birth

mm/dd/yy

Is there an Additional Owner?

Yes No

Owner #3 Data

Name

Phone Number

Address

State

Social Security Number

Date of Birth

mm/dd/yy

% of Business Ownership

Title or Position

Married?

Yes No

Spouse Name

Social Security Number

Date of Birth

mm/dd/yy

Bond Request / Project Data

Anticipated Start Date

mm/dd/yy

Time for Completion

Maintenance Period

Liquidated Damages

Project Name

Obligee (Who is requiring the contractor to get a bond?)

Obligee Type

Please explain other obligee type

Obligee Address

State

Job Legal Description (Scope of Work)

Job Physical Address

State

*This application is not intended for use in connection with Design-Build contracts, Subdivision or Site Improvement over $100,000 Asbestos Abatement, Completion, Hazardous Materials, or Multi-Year Contracts where term of contract is over 5 years

For private jobs or subcontracts, please enclose a copy of the contract and bond form for projects over $150,000.
For service type contracts, provide a copy of the contract.

Bond Category (Check one only)

Bid Date

Bond Amount

Estimated total amount of bid

Engineers Estimate (if any)

Bid Bond %, or flat amount

Status of Outstanding Bids or Performance:

Bond #

Bid Awarded?

No Yes

Bond #

Bid Awarded?

No Yes

Contract Price

Contract Date (Date when contract is signed)

Stand Alone Maintenance Bond Amount

Bid Secured by

Check Bond Negotiated

Next three lowest bidders (If truly negotiated, check box)

Bid #1

Bid #2

Bid #3

Federal Contract #

State Incorporation

Business Financial Data

Check option that applies to your business

Company Financial Requirements for (C) Corporations, (S) Corporations, and LLCs: Business Financial Requirement for Sole Proprietorships and Partnerships:

Please provide the company's last 2 years fiscal year-end financial statement or tax return. If the latest fiscal year financial statement or tax return is more than 6 months old, then also provide a current interim financial statement. (Upload Documents below)

FILE UPLOAD #1

FILE UPLOAD #2

Please provide the last 2 years fiscal year-end financial statement on the business. If the fiscal year-end statement on the business is more than 6 months old, then also provide us with a current interim financial statement. (Upload Documents below)

FILE UPLOAD #1

FILE UPLOAD #2

Does the contractor have a formal bank line of credit?

Yes No

Amount of line of credit?

Amount currently borrowed?

Personal Financial Data

Please provide a copy of each owner's latest personal financial statement. If the personal financial statement is more than 6 months old then provide us with a current statement. (Upload Documents Below)

FILE UPLOAD #1

FILE UPLOAD #2

FILE UPLOAD #3

Experience Data

List the three largest contracts completed in the last five years

Contract #1

Owner or General

Kind of work

Location (City/County, State)

Contract Price

% of Completion

Year Completed

Final Gross Profit

Contact Person

Phone

Email

Contract #2

Owner or General

Kind of work

Location (City/County, State)

Contract Price

% of Completion

Year Completed

Final Gross Profit

Contract #3

Owner or General

Kind of work

Location (City/County, State)

Contract Price

% of Completion

Year Completed

Final Gross Profit

List the two largest jobs you presently have underway, giving the following information

Current Job #1

Owner or General

Kind of work

Location (City/County, State)

Contract Price

% of Completion

Estimated Gross Profit

Date to be Completed

Current Job #2

Owner or General

Kind of work

Location (City/County, State)

Contract Price

% of Completion

Estimated Gross Profit

Date to be Completed

Operations Data

Liability Insurance Company and Limits

Expiration Date

Type of trades you perform

Territory in which you perform work (present and planned)

Trades Subcontracted

Year

Number of Jobs

Average Job Size

Average To

General Data

Disputes, Financial Difficulties, Problems, Etc. (For Company)

Failed in business or declared bankruptcy?

Yes No

Any Officer or Partner?

Yes No

Failed to complete a job or been assessed with delay damages

Yes No

Any Officer or Partner?

Yes No

Been involved in any lawsuits or disputes in the last 5 years

Yes No

Any Officer or Partner?

Yes No

Do you have any corporate or personal assets held in trust or escrow accounts

Yes No

Any Officer or Partner?

Yes No

Are any business or personal assets restricted or pledged for any purpose (i.e. collateral for a loan, etc.)

Yes No

Any Officer or Partner?

Yes No

Were you bonded in the past - By whom?

Yes No

Any Officer or Partner?

Yes No

Explain all “checked" answers fully below

Additional Information & Comments

Agency Data

Bernard Fleischer and Sons Inc.

Any person who knowingly and with intent to defraud any insurance company or person files an application 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 under applicable law.
The applicants and indemnitors certify the truth of all statements in the application and authorize the Company to verify this information and to obtain additional information from any source including obtaining a credit report.