RAP App
This program is not intended for use on the following types of contracts; • Subdivision • Indefinite Quantity • Efficiency Guarantees • Completion • Service Contracts • Software Programs • Multi-year Terms • Design Build • Sovereign Nation Owners
• Environment Issues/Hazardous Material Remediation • Long-term Maintenance Guarantee
CONTRACTOR INFORMATION - Attach most recent company year-end financial statement or tax return. Company Name: (Full Legal Name and DBA's) Type of Organization:
Corporation
LLC
S Corp
Partnership
Individual
Business Address:
Phone: Years Under Current Management:
Year Started:
Prior Surety:
Total Open Bond Amount $
Largest Contract Completed: Amount:
Date Completed:
Description:
Owner:
Contact Name:
Phone:
Largest Supplier Name:
Phone:
Has this company, owner or predecessor ever failed in business or declared bankruptcy?
Yes
No
Has this company, owner or predecessor ever defaulted on a contract or been involved in a surety claim?
Yes
No
Has this company, owner or predecessor been involved in any lawsuits, liens, or contract disputes in last 5 years?
Yes
No
Are there any assets pledged, restricted, or held in trusts?
Yes
No
Please explain any "Yes" answers on a separate page. Is this a single bond request or to establish an ongoing bond program? Bank Name:
Single Request
Ongoing Bond Program
Line of Credit Available: Phone:
Contact Name:
OWNER INFORMATION - Attach most recent personal financial statement. List Company Owners - if more than 2 owners, please complete Additional Owners Form. Owner: Spouse/Legal Domestic Partner:
Social Security #:
Date of Birth:
Social Security #:
Date of Birth:
Home Address:
Own Your Home:
% of Company Owned: Owner: Spouse/Legal Domestic Partner:
No
Yes
No
Position in Company: Social Security #:
Date of Birth:
Social Security #:
Date of Birth: Own Your Home:
Home Address: % of Company Owned:
Yes
Position in Company:
Agency Name:
How long have you known the Contractor?
Experience and Recommendation:
NOTICE: In requesting a bond from Merchants Bonding Company (Mutual) you are hereby notified the Company may request a consumer credit report for all applicants for underwriting purposes. The applicant certifies that all information provided in this application is true and accurate. Sign by the X and print name legibly next to the signature. Applicant:
X
Printed Name:
Date:
Producer:
X
Printed Name:
Date:
MERCHANTS BONDING COMPANY (MUTUAL) • MERCHANTS NATIONAL BONDING, INC. P.O. Box 14498 • DES MOINES, IOWA 50306-3498 • (800) 678-8171 • (515) 243-3854 FAX
SUP 0098-0008 MO (2/15)
• Environment Issues/Hazardous Material Remediation • Long-term Maintenance Guarantee
CONTRACTOR INFORMATION - Attach most recent company year-end financial statement or tax return. Company Name: (Full Legal Name and DBA's) Type of Organization:
Corporation
LLC
S Corp
Partnership
Individual
Business Address:
Phone: Years Under Current Management:
Year Started:
Prior Surety:
Total Open Bond Amount $
Largest Contract Completed: Amount:
Date Completed:
Description:
Owner:
Contact Name:
Phone:
Largest Supplier Name:
Phone:
Has this company, owner or predecessor ever failed in business or declared bankruptcy?
Yes
No
Has this company, owner or predecessor ever defaulted on a contract or been involved in a surety claim?
Yes
No
Has this company, owner or predecessor been involved in any lawsuits, liens, or contract disputes in last 5 years?
Yes
No
Are there any assets pledged, restricted, or held in trusts?
Yes
No
Please explain any "Yes" answers on a separate page. Is this a single bond request or to establish an ongoing bond program? Bank Name:
Single Request
Ongoing Bond Program
Line of Credit Available: Phone:
Contact Name:
OWNER INFORMATION - Attach most recent personal financial statement. List Company Owners - if more than 2 owners, please complete Additional Owners Form. Owner: Spouse/Legal Domestic Partner:
Social Security #:
Date of Birth:
Social Security #:
Date of Birth:
Home Address:
Own Your Home:
% of Company Owned: Owner: Spouse/Legal Domestic Partner:
No
Yes
No
Position in Company: Social Security #:
Date of Birth:
Social Security #:
Date of Birth: Own Your Home:
Home Address: % of Company Owned:
Yes
Position in Company:
Agency Name:
How long have you known the Contractor?
Experience and Recommendation:
NOTICE: In requesting a bond from Merchants Bonding Company (Mutual) you are hereby notified the Company may request a consumer credit report for all applicants for underwriting purposes. The applicant certifies that all information provided in this application is true and accurate. Sign by the X and print name legibly next to the signature. Applicant:
X
Printed Name:
Date:
Producer:
X
Printed Name:
Date:
MERCHANTS BONDING COMPANY (MUTUAL) • MERCHANTS NATIONAL BONDING, INC. P.O. Box 14498 • DES MOINES, IOWA 50306-3498 • (800) 678-8171 • (515) 243-3854 FAX
SUP 0098-0008 MO (2/15)
