Form 94A "Bond of Public Insurance Adjuster" - California

What Is Form 94A?

This is a legal form that was released by the California Department of Insurance - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2017;
  • The latest edition provided by the California Department of Insurance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 94A by clicking the link below or browse more documents and templates provided by the California Department of Insurance.

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Download Form 94A "Bond of Public Insurance Adjuster" - California

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State of California
Department of Insurance
Bond of Public Insurance Adjuster
Form 94A (Rev. 4/2017)
California Code of Regulations Title 11 section 50.21
Producer Licensing Bureau
P.O. Box 1139
SACRAMENTO, CA 95812-1139
Information (800) 967-9331 Or (916) 322-3555
www.insurance.ca.gov
State of California
Department of Insurance
Bond of Public Insurance Adjuster
(California Insurance Code sections 15011(g), 15033-15037)
BOND No. ___________________
PREMIUM $ _________________
KNOW ALL BY THESE PRESENTS:
That we__________________________________________ an applicant for or holder of
a California Public Insurance Adjusters license, whose address upon which process may be
served is _____________________________________________________________________
____________________________________________________________, as PRINCIPAL, and
___________________________________________, a corporation authorized to transact a
surety business in the State of California, as SURETY, whose address upon which process may
be served is ___________________________________________________________________,
are held and firmly bound to the People of the State of California in the penal sum of TWENTY
THOUSAND DOLLARS ($20,000), for which payment we bind ourselves, our heirs, executors,
administrators, successors and assigns jointly and severally, firmly by these presents.
WHEREAS, the provisions of Insurance Code section 15011(g) require that the
PRINCIPAL file a bond in connection with said Public Insurance Adjuster license and this bond
is executed and tendered in accordance therewith,
THE CONDITION OF THIS OBLIGATION IS SUCH,
That if the PRINCIPAL shall conduct business, including adjusting claims for fire and
allied coverages, burglary, flood and all property claims both real and personal, and loss of
income in a faithful and honest manner, then this obligation shall be null and void; otherwise it
shall remain in full force and effect.
State of California
Department of Insurance
Bond of Public Insurance Adjuster
Form 94A (Rev. 4/2017)
California Code of Regulations Title 11 section 50.21
Producer Licensing Bureau
P.O. Box 1139
SACRAMENTO, CA 95812-1139
Information (800) 967-9331 Or (916) 322-3555
www.insurance.ca.gov
State of California
Department of Insurance
Bond of Public Insurance Adjuster
(California Insurance Code sections 15011(g), 15033-15037)
BOND No. ___________________
PREMIUM $ _________________
KNOW ALL BY THESE PRESENTS:
That we__________________________________________ an applicant for or holder of
a California Public Insurance Adjusters license, whose address upon which process may be
served is _____________________________________________________________________
____________________________________________________________, as PRINCIPAL, and
___________________________________________, a corporation authorized to transact a
surety business in the State of California, as SURETY, whose address upon which process may
be served is ___________________________________________________________________,
are held and firmly bound to the People of the State of California in the penal sum of TWENTY
THOUSAND DOLLARS ($20,000), for which payment we bind ourselves, our heirs, executors,
administrators, successors and assigns jointly and severally, firmly by these presents.
WHEREAS, the provisions of Insurance Code section 15011(g) require that the
PRINCIPAL file a bond in connection with said Public Insurance Adjuster license and this bond
is executed and tendered in accordance therewith,
THE CONDITION OF THIS OBLIGATION IS SUCH,
That if the PRINCIPAL shall conduct business, including adjusting claims for fire and
allied coverages, burglary, flood and all property claims both real and personal, and loss of
income in a faithful and honest manner, then this obligation shall be null and void; otherwise it
shall remain in full force and effect.
This bond shall be deemed continuous in form and shall remain in full force and effect
and shall run concurrently with the license period for which the license is granted and each and
every succeeding renewal period or periods, or until the bond is canceled by the Surety. The
Surety may cancel the bond and be released of further liability hereunder by delivering 30 days’
notice to the Commissioner. Such cancellation shall not affect any liability incurred or accrued
prior to the termination of the 30-day period, after which liability hereunder shall cease except as
to any liability or indebtedness therefor incurred or accrued hereunder.
The aggregate liability of the Surety hereunder on all claims whatsoever shall not
exceed the penal sum of this bond.
This bond is executed by the Surety to comply with and the bond shall be subject to the
provisions of Chapter 2 (commencing with section 15000), of Division 5 of the California
Insurance Code and to the provisions of Chapter 2 (commencing with section 995.010) of Title
14 of Part 2 of the California Code of Civil Procedure.
By executing this bond, Principal and Surety agree any action on this bond shall be
instituted and prosecuted in the counties of the State of California, with service by U.S. mail as
prescribed in the California Code of Civil Procedure sections 417.10 and 417.20 and this bond
shall be governed by the laws of the State of California.
Dated: _________________
__________________________________________
Name of Public Adjuster
By_______________________________________
__________________________________________
Name and Title of Signator
Dated: _________________
__________________________________________
Name of Surety
By_______________________________________
__________________________________________
Name and Title of Signator
By_______________________________________
__________________________________________
Name and Title of Signator
SEAL
I certify (or declare) under penalty of perjury under the laws of the State of California that I have
executed the foregoing bond under an unrevoked Power of Attorney.
Executed in ____________________________________________ on ____________________,
(city and state)
(date)
_________________________________________
(Signature of Surety or Surety’s Attorney-in-Fact)
Note:
For instructions as to execution by principal and surety and for form of entity
acknowledgement and for form of acknowledgement by individual adjuster, see California Code
of Regulations, title 11, section 50.20.
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