Form FIS0858 "Insurance Premium Finance Company Corporate Surety Bond" - Michigan

What Is Form FIS0858?

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

Form Details:

  • Released on May 1, 2015;
  • The latest edition provided by the Michigan Department of Insurance and Financial Services;
  • 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 FIS0858 by clicking the link below or browse more documents and templates provided by the Michigan Department of Insurance and Financial Services.

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Download Form FIS0858 "Insurance Premium Finance Company Corporate Surety Bond" - Michigan

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FIS 0858 (5/15) Department of Insurance and Financial Services
Page 1 of 1
Insurance Premium Finance Company Corporate Surety Bond
Bond Number:
Effective Date of Bond:
Premium Finance Company Licensee Name:
Corporate Surety Name:
(Referred to as PRINCIPAL throughout this bond)
(Referred to as SURETY throughout this bond.)
Must be licensed to write surety business in Michigan.
Address:
Address:
City:
State:
ZIP Code:
City:
State:
ZIP Code:
PRINCIPAL and SURETY agree to be jointly and severally bound to the People of the State of Michigan as identified in Section 1504(2) of P.A. 352
of 1968, in the amount of $10,000 in United States currency. This agreement binds heirs, our executors, administrators, successors, assigns and
ourselves.
PRINCIPAL proposes to finance insurance premiums in the State of Michigan and agrees not to, directly or indirectly, or by his employee or agent,
violate the provisions of P.A. 352 of 1968, as amended. If PRINCIPAL performs as agreed, this obligation will be void and have no effect; otherwise,
the agreement will be in full force.
Liability of SURETY for aggregate claims arising in any license year will not exceed $10,000.
SURETY is liable for any claims that accrue from the effective date until the date of cancellation. SURETY must provide the Director of the
Department of Insurance and Financial Services with a written notice of cancellation at least 60 days prior to the cancellation date.
Seal of Principal
PRINCIPAL:
Signature of Principal:
Date signed:
Print Name & Title of Principal/Authorized Representative:
Signature of Secretary/Witness:
Print Name of Secretary/Witness:
Seal of Principal
SURETY:
Signature of Surety:
Date signed:
Print Name & Title of Surety:
When complete, submit to:
Mailing Address:
Delivery Address:
DIFS Insurance Licensing
DIFS Insurance Licensing
OR
PO Box 30220
530 W Allegan Street, 7th Floor
Lansing MI 48909-7720
Lansing MI 48933-1521
PA 352 of 1968 requires submission of this form. Failure to complete and submit this form could result in denial of your application for licensure.
FIS 0858 (5/15) Department of Insurance and Financial Services
Page 1 of 1
Insurance Premium Finance Company Corporate Surety Bond
Bond Number:
Effective Date of Bond:
Premium Finance Company Licensee Name:
Corporate Surety Name:
(Referred to as PRINCIPAL throughout this bond)
(Referred to as SURETY throughout this bond.)
Must be licensed to write surety business in Michigan.
Address:
Address:
City:
State:
ZIP Code:
City:
State:
ZIP Code:
PRINCIPAL and SURETY agree to be jointly and severally bound to the People of the State of Michigan as identified in Section 1504(2) of P.A. 352
of 1968, in the amount of $10,000 in United States currency. This agreement binds heirs, our executors, administrators, successors, assigns and
ourselves.
PRINCIPAL proposes to finance insurance premiums in the State of Michigan and agrees not to, directly or indirectly, or by his employee or agent,
violate the provisions of P.A. 352 of 1968, as amended. If PRINCIPAL performs as agreed, this obligation will be void and have no effect; otherwise,
the agreement will be in full force.
Liability of SURETY for aggregate claims arising in any license year will not exceed $10,000.
SURETY is liable for any claims that accrue from the effective date until the date of cancellation. SURETY must provide the Director of the
Department of Insurance and Financial Services with a written notice of cancellation at least 60 days prior to the cancellation date.
Seal of Principal
PRINCIPAL:
Signature of Principal:
Date signed:
Print Name & Title of Principal/Authorized Representative:
Signature of Secretary/Witness:
Print Name of Secretary/Witness:
Seal of Principal
SURETY:
Signature of Surety:
Date signed:
Print Name & Title of Surety:
When complete, submit to:
Mailing Address:
Delivery Address:
DIFS Insurance Licensing
DIFS Insurance Licensing
OR
PO Box 30220
530 W Allegan Street, 7th Floor
Lansing MI 48909-7720
Lansing MI 48933-1521
PA 352 of 1968 requires submission of this form. Failure to complete and submit this form could result in denial of your application for licensure.