1 confirm your bond informationAre you an Insurance Agent completing this application on behalf of a client? ** Yes No Agency Name* Agent Name* Agent's Email Address* Agent's Phone Number* Note: If you are currently registered as an agent with BondsExpress.com we will mail a commission check to you within one month of your surety bond purchase. If an updated E&O policy or business license is required, one of our agents will contact you promptly.Legal Business Name* This is the name that will appear on the bond.Tax ID/FEIN NPI #* Your NPI (National Provider Identifier) is issued by CMS. Your NPI should be 10 digits in length.NSC/PTAN # (If you have one) Address of Business* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Business TypeSelectIndividualCorporationPartnershipLLCLLPYear Business Started* Bond Amount Description of Business* What type of work does your company do that CMS is requiring this bond?Has the Company, Any Predecessor Company, or Any Owner Ever: a) Failed in business or been in bankruptcy?* Yes No b) Been in a claim with a surety company?* Yes No c) Within the past 7 years, been in involved in any lawsuits?* Yes No d) Had a tax lien exceeding $1,000?* Yes No Please explain any "Yes" answers* For How Many Years Have You Participated in Medicare?*Please enter a number greater than or equal to 0.If New to Working with Medicare, Enter a Zero "0"Accreditation Organization* Date of Accreditation (MM/YYYY)* Approximate Amount of Medicare Billings for Last Year*Approximate Amount of Medicare Billings for Two Years Ago*Expected Amount of Medicare Billings for Next Year*Date of Your Last Audit by Medicare (MM/YYYY) Any Citations or Problems Reported in Audit?* Yes No If Yes, Please Explain* Has Any Predecessor Company, Owner or Officer Ever had a Medicare or Medicaid License Revoked, or Experienced an Adverse Legal Action Relative to Medicare or Medicaid?* Yes No If Yes, Please Explain* Is the Company Currently Licensed by A State Board to Operate as Pharmacy, Optician, Hospital/Clinic/Skilled Care Facility?* Yes No License Number* Issuing State*Please Select OneAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming2 Enter owner informationName of Owner* First Middle Last Suffix Owner's Address* Street Address Address Line 2 City State Select StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code Do You Own Your Home?* Yes No AGENTS: Please enter your agency's phone and email address on the "Phone Number" and "Email Address" lines below, not the client's.Phone Number:* Email Address:* Social Security Number* Date of Birth MM slash DD slash YYYY MarriedSelectYesNoNumber of Owners*Number of Owners1 Owner2 Owners3 Owners4 Owners5 Owners6 Owners7 Owners8+ Owners9 Owners10+ OwnersAdditional Owner Information*Name, Address, home owner Y/N, Social Security Number, Date of Birth, and % of Ownership for each ownerCredit Authorization:* Credit Inquiry Notice: If needed to facilitate the underwriting review process and obtain the best possible rate for your surety bond, BondsExpress.com may pull a soft credit report. This credit inquiry does not affect your credit in any way whatsoever. If you have any questions regarding this type of credit inquiry, please contact us. I agree.CAPTCHA
