Express Desk

Llene la información a continuación para que uno de nuestros representantes se comunique con usted.

  • Fecha *
    MM slash DD slash YYYY
  • Productor *
  • INFORMACIÓN DEL CLIENTE / CLIENT INFORMATION

  • Principal *
    Principal
  • Nombre del Dueño *
    Owner Name
  • Dirección Postal *
    Postal Address
  • Dir. Física del Negocio *
    Business Physical Adress
  • Núm. de Teléfono *
    Phone Number
  • Correo electrónico *
    Email
  • Seguro Social Patronal Patronal *
    Social Security
  • Tipo de negocio *
    Type of business
  • Tiempo Establecido *
    Time Established
  • Seguro Social *
    Social Security
  • TIPOS DE FIANZAS / TYPE OF BOND

  • Límite *
  • Número de cuenta (AAA o AEE) *
  • Esta solicitud aplica a fianzas con un límite máximo de $10,000 y está sujeto a aprobación.

  • INDEMNITY AGREEMENT

  • The undersigned Applicant and Indemnitor(s), all hereinafter referred to as “Indemnitors,” hereby certify that the declarations made and answers given are the truth rithout reservation, and are made for the purpose of inducing ANTILLES INSURANCE COMPANY, any of their present or future direct or indirect parent companies, any of the respective present or future direct or indirect affiliates or subsidiaries of such companies and parent companies. And or any of the aforementioned entities’ successors or assigns. hereinafter referred to, individually and or collectively, as “Company,” to furnish a certain bond or undertaking applied for and any renewal and increase of the same or of any bond or undertaking of similar nature given in substitution or renewal thereof (all comprehended in the word Bond” as herein used). lndemnitors agree that Company may decline the Bond applied for or may cancel or terminate same without incurring Liability whatsoever to Indemnitors. In consideration of Company executing said Bond or the forbearance of cancellation of said Bond, Indemnitors do undertake and agree as follows:


    Indemnitors will pay all premiums, as they fall due, until Company has been provided with competent legal evidence that the Bond has been duly discharged. Indemnitors will at all times indemnify and exonerate Company from and against any and all loss, cost and expense of whatever kind which it may incur or sustain as a result of or in connection with the furnishing of the Bond and or the enforcement of this Agreement, including unpaid premiums, interest, court costs and counsel fees, and any expense incurred or sustained by reason of making any investigation. To this end Indemnitors promise: a) to promptly reimburse Company for all sums paid and b) to deposit with Company on demand an amount sufficient to discharge any claim made against the Company on the Bond. This sum may be used by Company to pay such claim or be held by Company as collateral security against loss or cost on the Bond.


    Indemnitors hereby expressly authorize Company to access credit records and to make such pertinent inquiries as may be necessary from third party sources for underwriting purposes, claim purposes and or debt collection. To the extent required by law, Company will, upon request, provide notice whether or not a consumer report has been requested by Company, and if so, the name and address of the consumer reporting agency furnishing the report.


    Regardless of the date of signature(s), this Agreement is effective as of the date of execution of the Bond and is continuous until Company is satisfactorily discharged from liability pursuant to the terms and conditions contained herein. An Indemnitor may terminate participation in this Agreement with respect to future renewals or substitution bonds or undertakings by providing written notice to Company of such intent to terminate. Such notice shall be addressed to ANTILLES INSURANCE COMPNAY, Attention: Surety Department, PO Box 9023507, San Juan, PR 00902-3507 and shall become effective sixty (60) days after Company’s receipt of the same. Termination hereunder shall not relieve the terminating Indemnitor(s) from liability with respect to any renewals or substitution bonds or undertakings issued, or for which Company has obligated itself to issue, before the effective date of termination.


    Attention: Any person who knowingly and with intent to defraud a surety company or any other person files an application for a surety bond containing any materially false inform atioii, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent act and may be subject to civil and/or criminal penalties.



  • Signed this day of: *
    MM slash DD slash YYYY
  • Indemnitor Sign Here *
  • Witness Sign Here *
  • Print Name *
  • Print Name *
  • Social Security *
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