I (We) hereby authorize Worldwide Insurance Specialists Inc. "WWISINC" herein called COMPANY to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any credit entries in error to COMPANY Credit Card or Bank account. Note: Direct Electronic check payment(s) from your account (ACH) funds may not be available until the second business day after the day of your transaction authorization.
BANK OR FINANCIAL INSTITUTION herein called DEPOSITORY
This authorization allows the COMPANY to make a ONE TIME debit of the account for the amount shown above. It is to remain in full force and effect until the company has received written notification from COMPANY (or you) of termination and is received in such time and in such a manner to afford the COMPANY and DEPOSITORY a reasonable opportunity to act.
ALL CREDIT AUTHORIZATIONS PROVIDE THAT THE RECEIVER MAY REVOKE THE AUTHORIZATION BY NOTIFYING THE COMPANY
The above is only a conditional offer and is subject to change or rescission based upon a multitude of considerations. The above quoted may include a broker fee. Therefore, the undersigned hereby agrees that if a fee is charged, to pay the fee in the amount as shown above. The first years premium is the amount of money you paid for the bond to the Surety company who issued the initial bond. If a new Surety issues a new bond in the same period or new period, the initial premium may be fully earned. First Years premium, renewals, minimum premiums and commission are fully earned, upon issuance of the Insurance/bond(s), unless prohibited by law, or is contrary to Surety's or Insurance Company’s filed rates. If the Insurance/ Bond(s) are canceled midterm, the commission shall also be considered a fee, and fully earned. The amount of the bond premium you may get back is at the discretion of the initial Surety or COMPANY and the time of cancellation. In addition, fees and premiums may earn interest. This undeclared income is non-refundable and fully earned as well as any fees charged. In addition, the COMPANY may also be acting on behalf of the insurer issuing the subject Bond(s) or Insurance and will be receiving a commission. Additional information may be required by the COMPANY to complete underwriting or re-instatement of the surety bond.
Riders/ Duplicate Bonds:
If a Rider is issued due to incorrect information provided to the COMPANY and the bond has left our office the principal will incur a Rider fee. If the bond is lost / destroyed and a duplicate bond is issued the principal will incur a fee.
(If applicable), Collateral will be held until the Surety's liability has been extinguished Please read the Collateral Agreement carefully.
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 shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation *State of NY only.
Fair Credit Reporting Act Notice:
This notice is given to comply with the Federal fair Credit Reporting Act (Public law 91-508) and any similar state law which is applicable. As part of our underwriting procedure, a routine credit report may be pulled on any applicant or indemnitor which will provide information concerning credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics and mode of living. Upon request, additional information as to the nature and scope of the report, if one is made, will be provided.
Hold Harmless: The Principal and its employees or Agent/Broker shall be responsible for any and all liability resulting from its own acts and omissions as well as the acts and omissions of its sub-agents, sub-brokers, and its and their employees, and shall indemnify the COMPANY and hold harmless for any claims or damages arising therefrom, including any award, judgment, penalties, fees, costs of court, and or reasonable attorneys’ fees incurred in defending same. If any portion of this Agreement is unenforceable that portion shall be considered deleted with the remainder to continuing in full force and effect.
This agreement shall serve as the writing required pursuant to the rules set forth by your Department of Insurance (Broker/Agents shall comply with their applicable state regulations regarding fees). **Fees include processing, state tax, surplus tax, brokers and commission fee where applicable. I, the undersigned, hereby apply for a Bond to the Surety Company (“SURETY”) through Worldwide Insurance Specialists, Inc. (“WWIS, INC”), with whom I hereby grant the authority to act on my behalf with respect to the bond and assign as my Broker of Record. In consideration of SURETY issuing, renewing or substituting said bond(s), I, individually and as the owner, officer or Insurance Agent of the bonded entity, hereby understand and agree to these terms.