Contractors Surety Questionnaire The information requested in this questionnaire is required for us to consider your company for bonding. Please be as thorough as possible when you answer the questions. We request that you answer all of the questions so that we will properly understand your business and we will not have to delay your application waiting for complete information. When you have completed and signed the form, please return it with the following: Business Financial Statements Please provide copies of the company s fiscal year-end statements for the last three (3) years. (CPA-prepared statements are preferred, if available) Personal Financial Statements (forms enclosed) - All owners must provide a personal financial statement. Similar, current forms are acceptable. Work on Hand Schedule (form enclosed) Please complete or provide a similar form on all jobs currently under contract. (bonded and un-bonded) Banking Reference (form enclosed) Please complete the top portion of the enclosed form, forward it to your bank(s), have your bank(s) fill out the bottom half of the form and return the original to our office. Insurance Information Please provide a current certificate of insurance from your insurance agent naming Bankers Surety Services, Inc. as the holder. Resume and Reference Letters Both are a good supplement to any submission, especially if you are a new business. Organizational structure chart Please provide copies of the company s organization structure chart. Articles of Incorporation Please provide a copy of the articles of incorporation. 1) Company Name: 2) Address: (Name as filed with Secretary of State, IRS) 3) Phone Number: 4) Fax Number 5) Federal Tax ID #: 6) Total # of Employees: 7) Type of Organization: Corporation Partnership Proprietorship Sub S Corp (please check one) 8) Date Business Formed: 9) Date Business Incorporated: 10) Overnight Service:: 11) Account Number: (i.e. FedEx, UPS, Airborne, etc.) to be used with your permission only 12) State of Incorporation:: 13) Fiscal Year End Date: Page 1 of 5
Company Ownership Information List All Owners and/or Stockholders of the Company (Attach separate sheet if there are more than 4 owners) 14) Name: Title: % Ownership: Social Security #: Birth Date: Home Phone: 15) Name: Title: % Ownership: Social Security #: Birth Date: Home Phone: 16) Name: Title: % Ownership: Social Security #: Birth Date: Home Phone: 17) Name: Title: % Ownership: Social Security #: Birth Date: Home Phone: 18) Have there been any changes in ownership in the past two years? Yes No If yes, please explain: 19) Is the Company or any of its owners connected with the other companies that operate as a parent, subsidiary, holding company or affiliate? Yes No If yes, please explain: 20) Have provisions been made for continuation of the duties of the owner(s) and an orderly transfer of ownership in the event of death or disability? Yes No If yes, please provide details: 21) Are there any problems with full corporate and personal indemnification (including spouse) by all owners and/or affiliates of the company? Yes No If yes, please explain: Page 2 of 5
Company s Operations/General Information 22) Key Operating Personnel: (Provide resumes if available) Name Position/Responsibility Age Time In Position Time In Industry 23) Control and supervision of contracts by owner(s) is performed on a : Daily Weekly Monthly basis. 24) What class of construction work does company: A. Generally do B. Specialize in C. At times handle 25) What is your geographic area of operations? 26) Are bonds required from subs or suppliers? Yes No If yes, over what amount? $ 27) What is the single largest contract you expect to attempt to obtain in the near future? $ 28) What is the largest total amount of work you anticipate to have at one time? $ 29) What is your total revenue projected for the next 1-year period? $ 30) Do you presently own the equipment necessary to complete the work program outlined above? Yes No If no, will you be buying renting leasing Anticipated total acquisition cost (including down payment) $ 31) Previous Bonding Companies: Agent Carrier Name Reason For Leaving 32) Has the company, any affiliate or subsidiary, or any owner(s) or spouse(s) or companies in which they have had an ownership interest: Ever defaulted on a contract? Yes No Ever defaulted on a contract forcing the surety to suffer a loss? Yes No Ever experienced a bankruptcy? Yes No Been in receivership? Yes No Been liened by a taxing authority? Yes No If yes was given as an answer to any of these questions, please provide us with a specific explanation as to what occurred: Page 3 of 5
Contract References List the 5 Largest Projects Completed in the Last 5 Years 33) Owner or GC: Contact Person: M/Yr Completed: 34) Owner or GC: Contact Person: M/Yr Completed: 35) Owner or GC: Contact Person: M/Yr Completed: 36) Owner or GC: Contact Person: M/Yr Completed: Contract Amount: $ Gross Profit: $ Was a Bond Required? 37) Owner or GC: Contact Person: M/Yr Completed: Banking Information 38) Name of Bank: Address: Phone Contact: Account Number(s): With Bank Since: Current Line Of Credit: $ Amount In Use: $ Secured by: Corporate Signature Personal Signature Accounts Receivable Inventory Other Please describe: Terms: Rate: Repayment: Page 4 of 5
Accounting Information 39) Name of CPA firm: Address: Phone Number: Contact Person: 40) On what basis are taxes paid? Cash Completed Job Accrual % of Completion 41) On what level of assurance are financial statements prepared? CPA Audit Review Compilation 42) How often are financial statements prepared? Annually Semi-Annually Quarterly Monthly Credit References 43) Give names of principal suppliers / subcontractors: Name of Firm & Contact Person Phone # Material/Services Provided The undersigned does hereby authorize Bankers Surety Services, Inc. to make inquires as necessary concerning or pertaining to the undersigned s financial standing, credit, or manner of meeting obligations to verify the accuracy of the statements made and to determine my credit worthiness. I certify the above and the statements contained in the attachments are true and accurate as of the stated date(s). A copy of this agreement shall be considered the same as the original. This authorization is to remain in full force until rescinded by the applicant in writing. These statements are made for the purpose of obtaining a bond. I understand FALSE statements may result in forfeiture of benefits and possible prosecution by the U.S. Attorney General (Reference 18. U.S.C. 1001). Dated this day of, 20 By: Title: Name of Company Page 5 of 5