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80 MAIN STREET, SUITE 330, WEST ORANGE, NJ 07052
973-731-7650 (P) 973-731-7889 (F) JBURGER@SERVICEBONDING.COM


SITE PLAN BOND APPLICATION

Please enter your name:
Date: Home Phone Number: Business Phone Number:
Name of Company:
Address:
City: State:
Zip Code:
Email Address:
Amount of Bond: $ Obligee/Township:


INDIVIDUALS, OFFICERS, STOCK HOLDERS & RELATED CORPORATIONS, LLC MEMBERS "PRINCIPALS"
Applicant Name:
Home Address:
Social Security Number:
% of Ownership: %
**please provide additional information on any other owners on page 2**
Name of Development:
Cost of Land: $ Cash Paid: $ Mortgages: $
How will mortgage be paid off? Date Purchased:
Estimated Cost of Improvements: $
Do you have a Development Improvement Loan: Yes No (provide copy) Amount: $
Number of Houses: Estimated selling price of each: $
Estimated Profit: Number of Deposits:
Scope of Project if Commercial:
CONTRACTOR TO PERFORM SITE IMPROVEMENT:
PREVIOUS EXPERIENCE OF APPLICANT
PROJECT NAME BONDING COMPANY #OF HOMES/SOLD STATUS OF WORK **PLEASE INCLUDE PHONE NUMBER OF TOWN ENGINEER PLEASE PROVIDE THE FOLLOWING ITEMS WITH APPLICATION:

1.Are you currently on notice of a pending or prior default (failure to perform or to make payments) on a bonded project? Y N
2.Ever filed bankruptcy Y N
3.Ever had a criminal conviction? Y N
4.Are there any unresolved lawsuits involving applicant/principal or spouse or a related business or any unpaid judgments or liens against applicant/principal or spouse, including judgments or liens in favor of any tax authority, IRS, any state agency or vendor or any pending or prior disputes, surety bond claim or other civil litigation? Y N

THIS IS TO CERTIFY THAT ALL OF THE ABOVE STATEMENTS ARE TRUE AND TO THE BEST OF MY KNOWLEDGE THERE ARE NO PRIOR, PENDING, OR NOTICE OF CLAIMS ON THIS ENTITY, RELATED ENTITY OR PRIOR BUSINESS I HAVE OR HAD OWNERSHIP IN OR THAT OF A FAMILY MEMBER EXCEPT FOR WHAT HAS BEEN DISCLOSED.

Fraud Statement We do not provide coverage where a person makes fraudulent statements to any insurance company, or where a person files an application for insurance or bonds or files a statement of claim containing any false information, or conceals for the purpose of misleading, information containing any material fact. The aforementioned acts constitute a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and stated value of the claim for each violation. In some states the aforementioned acts may be subject to criminal prosecution. I/WE AUTHORIZE THE COMPANY TO INVESTIGATE MY STATEMENT AND TO CHECK MY/OUR CREDIT WITH ANY CREDITORS OR LENDING INSTITUTIONS. THIS INCLUDES PERSONAL INFORMATION. I will check all bonds and related documents prior to submitting bonds and related documents or other types of bonds. I understand that The Service Insurance Company is not responsible or liable for rejected bonds or mistakes and I agree to hold The Service Insurance Company harmless should a bid or bond ever get rejected SIGNED THIS DAY OF


Name and Title:
Signature:
Name and Title:
Signature Agent/Broker:
Name of Insurance Agency: Phone Number