4299 Five Oaks Drive
Lansing, MI 48911
Phone: (517) 482-7900
Fax: (517) 482-1696
www.capitalinsurance.com
Surety Bond Quote Sheet
Business Name: __________________________________ FEIN #: _______________________ Year Established: _______
Phone: __________________________________________ E-Mail: _____________________________________________________
Location Address: ________________________________ City: _____________________ State: ______ Zip: _____________
Mailing Address: ________________________________ City: _____________________ State: ______ Zip: _____________
Contact Person: __________________________________ Phone: ___________________ Owner or Tenant: ______________
Description of Operations: ___________________________________________________ Years of Experience: ___________
Entity Type: ☐ Sole Proprietorship ☐ Partnership / LLP ☐ Corporation ☐ LLC
☐ PC ☐ Other (list): ______________________________________________________________
Years Licensed: _______________ Bond Amount: ________________ License No: _____________________
Effective Date: ________________ Name & Address of Obligee: _______________________________________
_______________________________________
_______________________________________
Bond Type Requested (please select one)
Appraisal Bond Financial Obligation Motor Vehicle Dealer or Title
(Collection/Debt)
Erisa (Pension/Profit Sharing Plan) Financial Obligation (Mortgage Notary
Banker/Broker)
Escrow Bond License/Permit Bond Probate or Fiduciary
Fidelity (Name or Position Schedule) Liquor Bond Public Official Bond
General Underwriting Questions (required for all applicants)
Does the applicant have any other Surety bonds in force? ☐ No ☐ Yes
Has another Surety company declined to write this or any previous bond? ☐ No ☐ Yes
Have you ever had a bond involuntarily terminated or cancelled? ☐ No ☐ Yes
Has there ever been a claim or legal action against any bond executed on your behalf? ☐ No ☐ Yes
Do you or any of your companies have any pending lawsuits, unsatisfied judgements or
☐ No ☐ Yes
liens?
Have you or any of your companies declared bankruptcy or become insolvent? ☐ No ☐ Yes
Have you or any of your companies been the subject of any legal or administrative
☐ No ☐ Yes
proceedings resulting in disciplinary action?
Have you ever been convicted of a felony? ☐ No ☐ Yes
(If you answered yes to any of the above questions, please attach a detailed explanation.)
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Financial Statement as of ______________________
Check One: ☐ Business Financial Statement ☐ Personal Financial Statement
Current Assets Current Liabilities
Cash on hand (not in bank) Notes payable
Cash in banks Sales Contracts & Chattel Mtgs.
Stocks and bonds Accounts payable
Accounts receivable Current portion of long term debt
Notes receivable Other current liabilities
Other current assets Current Year’s Income Taxes Unpaid
Real estate Prior Year’s Income Taxes Unpaid
Residence Real Estate (1)
Other Real Estate (2)
Cash value of life insurance Total Liabilities
Other assets and investments Capital Stock (Paid In)
Total Fixed Assets Net Worth
Total Assets Total Liabilities & Net Worth
Current Insurance Information
Company Name: ________________________ Annual Premium: ______________ Expiration Date: _____________
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