Indemnitor Application & Agreement

Bail Bond Applicaton - Indemnitor

Step 1 of 10 - Defendant Name and Address

Defendant Information:
Defendant's Full Name
Date of Birth
Date Format: MM slash DD slash YYYY
Charges
Case Number
Court Name
Date to Appear
Date Format: MM slash DD slash YYYY
POA#

Indemnitor Name and Address:
Name
First Middle Last
My friends/family know me as
Relationship to Defendant
Home Phone
Cell Phone
Work Phone
Email
Current Address
Street Address Address Line 2 City State ZIP Code
How long?
Rent or Own?
- Rent
- Own
Landlord Name
Landlord Phone
Former Address
Street Address City State ZIP Code
How long?
Rent or Own?
- Rent
- Own
Landlord Name
Landlord Phone

Personal Description
Date of Birth
Date Format: MM slash DD slash YYYY
Place of Birth
Male or Female?
- Male
- Female
Social Security Number
Driver's License Number
Issuing State
How long in the US?
US Citizen?
- Yes
- No
Race
Alien Number
Additional Notes

Employment
Employer
Position
How Long
Employer Address
Street Address City State ZIP Code
Supervisor's Name
Phone Number
Union
Local #
Military Branch
Active?
Discharge Date
Date Format: MM slash DD slash YYYY

Marital Status/Children
- Single
- Married
- Cohabitating
- Separated
- Divorced
- Widowed
Significant Other Name
Years Together
Email
Address
Street Address City State ZIP Code
Home Phone
Cell Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Employer
How Long?
Phone Number
Significant Other Mother Name
Phone Number
Significant Other Father Name
Phone Number
Former Significant Other Name
Years together
Email
Address
Street Address City State ZIP Code
Home Phone
Cell Phone
Date of Birth
Date Format: MM slash DD slash YYYY
Employer
How Long?
Phone Number

Vehicle:
Year
Make
Model
Color
Plate Number
State
Where Financed
Amount Owed

References
Name
Relation
Address
Street Address City State ZIP Code
Employer
Home Phone Number
Work Phone Number
Cell Phone Number
Name
Relation
Address
Street Address City State ZIP Code
Employer
Home Phone Number
Work Phone Number
Cell Phone Number
Name
Relation
Address
Street Address City State ZIP Code
Employer
Home Phone Number
Work Phone Number
Cell Phone Number

Social Network Information:
Facebook Account
Username
Password
Twitter Account
Username
Password
LinkedIn Account
Username
Password
Other
Type of Account
Username
Password

Financial Information
Cash on hand
Cash in bank
Real Estate Value
Real Estate Mortgage
In whose name is Title?
Monthly Salary or Wages

Authorized Signatures

I hereby represent and warrant that the foregoing information is true, complete and correct and is made for the purpose of inducing International Fidelity Insurance Company/Allegheny Casualty Company to issue, or cause to be issued, bail bond(s) for the defendant referred to herein.
Signed, sealed and delivered this
Date Format: MM slash DD slash YYYY
Indemnitor
DL#
SSN
Date of Birth
Date Format: MM slash DD slash YYYY
Signature
Print Name
Important Fraud Warnings:
NOT FOR USE IN NORTH CAROLINA
ALABAMA RESIDENTS Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.
ARKANSAS RESIDENTS Any person who knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
FLORIDA RESIDENTS Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
LOUISIANA RESIDENTS It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MAINE RESIDENTS It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
MARYLAND RESIDENTS Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
NEW JERSEY RESIDENTS Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.
NEW MEXICO RESIDENTS Any person who knowingly presents a false or fraudulent claim for payment or a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
OHIO RESIDENTS Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA RESIDENTS WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PENNSYLVANIA RESIDENTS Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 and subjects such person criminal and civil penalties.
RHODE ISLAND RESIDENTS It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
TENNESSEE RESIDENTS It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
VIRGINIA RESIDENTS It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
WASHINGTON RESIDENTS It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
WEST VIRGINIA RESIDENTS It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits

Bail Bond Applicaton - Indemnitor

Step 1 of 10 - Defendant Name and Address

Defendant Information:

Indemnitor Name and Address:

Personal Description

Employment

Marital Status/Children

Vehicle:

References

Social Network Information:

Facebook Account

Twitter Account

LinkedIn Account

Other

Financial Information

Authorized Signatures

Indemnitor

Important Fraud Warnings:

Note: Before you submit this form, please call us at 406-443-2665, so we can walk you through the process successfully.