Surety Application - Galloway Bail Bonds

Bond / Defendant Information

Defendant Name

First Last

Total Bond Amount

Bond Amount Written Out

Court

Power of Attorney Number(s), if known

1. Indemnitor Name and Address

Indemnitor Name

First Last

Nickname / Alias

Relationship to Defendant

Home Phone

Cell Phone(Required)

Work Phone

Email(Required)

Current Home Address

Street Address Address Line 2 City State ZIP Code

Current Home: Rent or Own?

Rent

Own

Current Landlord

How Long at Current Address?

Former Home Address

Street Address Address Line 2 City State ZIP Code

Former Home: Rent or Own?

Rent

Own

Former Landlord

How Long at Former Address?

2. Personal Description

Date of Birth

Where Born (City and State)

Sex

Race

Driver's License Number

Issuing State

How Long in U.S.?

U.S. Citizen?

Yes

Nationality

Alien Number

Union

Local Number

Military Service Branch

Active?

Discharge Date

Additional Notes

3. Employment

Occupation

Employer

Work Phone

How Long Employed?

Employer Address

Street Address Address Line 2 City State ZIP Code

Supervisor's Name

4. Marital Status

Marital Status

Spouse / Girl / Boyfriend Name

First Last

How Long Married / Together?

Spouse / Partner Address (if different)

Street Address Address Line 2 City State ZIP Code

Spouse / Partner Email

Spouse / Partner Home Phone, if different

Spouse / Partner Cell Phone

Spouse / Partner Occupation

Spouse / Partner Employer

Spouse / Partner How Long Employed?

Spouse / Partner Employer Phone

5. Automobile

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Color

Plate Number

Plate State

Where Financed?

Amount Owed

6. References

Reference 1 Name

First Last

Reference 1 Relation

Reference 1 Address

Street Address Address Line 2 City State ZIP Code

Reference 1 Employer

Reference 1 Home Phone

Reference 1 Work Phone

Reference 1 Cell Phone

Reference 2 Name

First Last

Reference 2 Relation

Reference 2 Address

Street Address Address Line 2 City State ZIP Code

Reference 2 Employer

Reference 2 Home Phone

Reference 2 Work Phone

Reference 2 Cell Phone

Reference 3 Name

First Last

Reference 3 Relation

Reference 3 Address

Street Address Address Line 2 City State ZIP Code

Reference 3 Employer

Reference 3 Home Phone

Reference 3 Work Phone

Reference 3 Cell Phone

7. Financial Statement / Credit Information

Cash on Hand

Cash in Bank

Real Estate Value

Real Estate Mortgage

In Whose Name is Title?

Monthly Salary or Wages

8. Notes

Notes

Indemnity Agreement

This Indemnity Agreement is entered into between the undersigned Indemnitor and Surety through Surety’s duly appointed independent bail producer.

You will have Defendant appear in any court required in connection with the bond(s) at the times stated in the bond(s) and all other times as may be ordered by the court.
You, jointly and severally with any other Indemnitor, shall indemnify the Surety and hold it harmless from losses, demands, liabilities, fees and expenses relating to or arising out of issuance or procurement of the Bond, including forfeiture or judgment on the Bond, court costs, interest, legal fees, fugitive recovery fees, extradition costs, collection costs and attorneys’ fees.
Any property or collateral deposited is security for payment of monies and sums due to Surety or Producer, including liabilities, demands, damages, judgments, interest, attorneys’ fees and costs relating to the Bond. If obligations are not performed, Surety may apply, hold or sell collateral as permitted by law.
Surety is not liable for depreciation of collateral or interest thereon. If collateral depreciates, you shall provide additional satisfactory collateral. If you fail to do so, Surety may sell, assign and deliver collateral as permitted by law.
If a confession of judgment is taken in connection with the Bond, Surety may enter and file it at any time, and such judgment may be a lien against your property.
Surety may foreclose liens and security interests or exercise rights and remedies without waiving other rights or remedies.
Surety will return collateral when Surety receives satisfactory written legal evidence of discharge or release from liability under the Bond, no outstanding liabilities remain, no other outstanding bonds or obligations require retention, and any required release is delivered.
Surety may transfer or assign its rights and obligations under this Agreement and/or the Bond without notice to or consent from you.
This Agreement and connected documents contain the full agreement between Surety and you. You agree to execute future documents necessary to carry out this Agreement.
You acknowledge that neither Surety nor Producer has recommended any specific attorney to represent Defendant.
This Agreement may not be terminated or modified orally; changes must be in writing and signed by Surety and you.
To the maximum extent permitted by law, you authorize Surety to obtain private or public information and records concerning you, including credit, Social Security, criminal, civil, driving, tax, telephone, medical, school, worker compensation and employment records. You authorize contacted parties or agencies to furnish such information.
You agree Surety may attach a location tracking device to any vehicle owned or driven by you and may use location technologies to locate your wireless device during the bail period and any applicable remission period. You will not have the option to opt out of location use or tracking during the bail period.
If any provision is deemed to exceed applicable law, it shall be revised to comply and the validity of other provisions shall not be affected.
You have not been paid to sign this Agreement. You have read the contract, understand it, and agree to fulfill all provisions.

Important Fraud Warnings

Alabama, Arkansas, Florida, Louisiana, Rhode Island, West Virginia, Maine, Tennessee, Virginia, Washington, Maryland, New Jersey, New Mexico, New York, Ohio, Oklahoma and Pennsylvania residents: The PDF includes state-specific warnings that knowingly presenting false, incomplete, misleading or fraudulent insurance information or claims may be a crime and may result in fines, confinement, restitution, civil penalties and/or criminal penalties.

Signature / Certification

Signed, Sealed and Delivered At

Signature Date

Witness Signature(Required)

Witness Printed Name

Indemnitor Signature

Indemnitor Printed Name

Surety:
Bankers Insurance Company
11101 Roosevelt Blvd. N.
St. Petersburg, FL 33716

Bail Producer Stamp / Information

SOUTH CAROLINA ADDENDUM TO INDEMNITOR APPLICATION AND AGREEMENT

This South Carolina Addendum (“Addendum”) is attached to and forms part of the Indemnitor Application and Agreement (“Agreement”) signed, sealed and delivered by You as Indemnitor and is incorporated into the Agreement by this reference. Any capitalized terms used in this Addendum without definition shall have the meanings assigned to these terms by the Agreement.

1. If you are depositing real or personal property as collateral for this bail bond, this disclosure shall apply:

Disclosure of Lien Against Property

Do not sign this document until you read and understand it. This bail bond will be secured by real or personal property you own or in which you have an interest. Failure to pay the bail bond premiums when due or the defendant’s failure to comply with the conditions of bail could result in the loss of your property.

2. Except as expressly provided in this Addendum, all terms and conditions of the Agreement remain in full force and effect. In the event of a conflict between the terms and conditions of the Agreement and this Addendum, this Addendum shall control.

3. This Addendum shall be attached to every Indemnitor Application and Agreement entered into in the State of South Carolina.

Date Signed

Signature of Indemnitor

Printed Name of Indemnitor

Bankers Insurance Company

DISCLOSURE NOTICE

CONDITIONS OF BOND:

The SURETY, as bail, shall have control and jurisdiction over the principal during the term for which the bond is executed and shall have the right to apprehend, arrest and surrender the principal to the proper officials at any time as provided by law.

In the event surrender of principal is made prior to the time set for principal's appearances, and for reason other than as enumerated below in paragraph 3, then payee shall be entitled to a refund of the bond premium.

It is understood and agreed that the happening of any one of the following events shall constitute a breach of principal's obligation to the SURETY hereunder, and the SURETY shall have the right to forthwith apprehend, arrest and surrender principal. Said events which shall constitute a breach of principal's obligations hereunder are:
1. If the principal shall depart the jurisdiction of the court without the written consent of the court and the SURETY or its Agent.
2. If principal shall move from one address to another without notifying the SURETY or its Agent in writing prior to said move.
3. If principal shall commit any act which shall constitute reasonable evidence of principal's intention to cause a forfeiture of said bond.
4. If principal is arrested and incarcerated for any other offense other than a minor traffic violation.
5. If principal shall make any material false statement in the application.

Other Conditions

Do you have a court date?

Yes

Court Date

Time

Place

INDEMNITOR INFORMATION

In addition to the terms and conditions of any Indemnity Agreement or other collateral documents which you have executed, this is to notify you that:

The Indemnitor(s) will have the defendant(s) forthcoming before the court named in the bond, at the time therein fixed, and as may be further ordered by the Court.

The Indemnitor(s) is responsible for any and all losses or costs of any kind whatsoever which the Surety may incur as a result of this undertaking. There should not be any costs or losses provided the defendant(s) does not violate the conditions of the bond and appears on time at all required Court hearings.

Collateral will be returned to the person(s) named in the collateral receipt, or their legal assigns, within 21 days after the Surety has received written notice of discharge of the bond(s) from the Court. It may take several weeks after the case(s) is disposed of before the court discharges the surety bonds.

PRINCIPAL ACKNOWLEDGMENT

I have read and received a copy of this Disclosure Notice. I fully understand and agree that any breach of the conditions listed above may result in my surrender.

Principal Signature

INDEMNITOR ACKNOWLEDGMENT

I have read and received a copy of this Disclosure Notice and understand and agree that should any breach of the conditions listed above occur, I may request/consent that the principal be surrendered by surety and agree to pay all costs incurred by Surety as a result of this undertaking. However, I do understand and agree that the Surety has no legal duty to comply with said request/consent made by indemnitor.

Indemnitor Signature

Galloway Bail Bonds Surety Application

Bond / Defendant Information

1. Indemnitor Name and Address

2. Personal Description

3. Employment

4. Marital Status

5. Automobile

6. References

7. Financial Statement / Credit Information

8. Notes

Indemnity Agreement

Important Fraud Warnings

Signature / Certification

SOUTH CAROLINA ADDENDUM TO INDEMNITOR APPLICATION AND AGREEMENT

Disclosure of Lien Against Property

Bankers Insurance Company

DISCLOSURE NOTICE

INDEMNITOR INFORMATION

PRINCIPAL ACKNOWLEDGMENT

INDEMNITOR ACKNOWLEDGMENT