"Surety Bond" - Louisiana

Surety Bond is a legal document that was released by the Louisiana Department of Insurance - a government authority operating within Louisiana.

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  • Released on November 2, 2009;
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SURETY BOND FILED WITH THE LOUISIANA DEPARTMENT OF INSURANCE
The text of this official Department of Insurance form is NOT to be altered under penalty of law.
This form is NOT to be used for Bonds for Home Service Contracts
STATE OF ___________________
COUNTY/PARISH OF __________________
PART 1. Bond & Surety. Complete All Information in Part 1, A-D.
A. Bond #
C(1). Describe This Bond (check one):
___Original
B. Bond Issue Date (insert mmddyyyy)
(This may not be the same as the
___Continuation
effective date, but this date must be on
or before the effective date.)
___Other. Specify: ___________________________________________________________________________________________________
C(2). Provide Effective Dates and Times of This Bond [complete all 4 blanks and circle AM or PM for each of C(2)(a) AND C(2)(b)]:
(a)
Effective (mmddyyyy): _________________________ at __________________ AM/PM
(b)
Terminates (mmddyy): _________________________ at __________________ AM/PM
D. Surety Company
1. Name
2. NAIC #
PART 2. Principal & TPA. Complete All Applicable Information in Part 2.
A.
1. Name
2. NAIC #
Principal
B. If TPA, Entity for Which TPA Administers—
1. Legal Name
 
Complete only if LRS 23:1196(C)(1) applicable
2. Physical Address
 
Part 3. Type and Bond Amount. Mark ONLY one type and amount of bond for one year commencing on the date stated hereinabove at Part 1C.
One Hundred Thousand
 
Fifty Thousand
Dollars ($100,000.00)
A. TPA-Bond in
Dollars ($50,000.00)
B. Public Adjuster-
current U.S. Dollars
Bond equal to Fifty
One Hundred Fifty
 
equal to
Thousand current
C. Surety Bond-Bond in
One Hundred
Thousand Dollars
U.S. Dollars
current U.S. Dollars equal to
Thousand Dollars
($150,000.00)
($50,000.00)
($100,000.00)
Two Hundred Fifty
 
Thousand Dollars
($250,000.00)
 
PART 4. KNOW ALL MEN BY THESE PRESENTS, THAT the Principal and Surety, who, after being duly sworn, deposed and said:
THAT they are firmly bound unto the Commissioner of Insurance, State of Louisiana, or his successor in office, under this bond delivered in lieu of deposit of securities conditioned only for and
dedicated exclusively to the prompt payment of all claims arising and accruing to any person by virtue of any policy issued, service agreed to, or fund established by the Principal, for the payment
 
of which the Principal and Surety bind themselves, their heirs, administrators, executors, successors and assigns, jointly and severally, by this agreement;
THAT the condition of this obligation is such that if the above named Principal shall well and faithfully discharge and perform the duties incumbent on him under the provisions of Titles 22 and 23
of the Louisiana Revised Statutes and all other applicable laws, then in such case the above obligation is to become null and void; else to remain in full force, effect and virtue;
 
THAT the provisions under Titles 22 and 23 of the Louisiana Revised Statutes and all other applicable laws for principals, sureties and third party administrators (where third party administrators
are parties) shall be applicable;
THAT this obligation may be continued for any subsequent year by a continuation certificate duly signed and sealed by the Principal and Surety, subject to the terms and conditions of the original
 
bond;
IN WITNESS WHEREOF, Principal and Surety have executed this bond on the dates stated hereinbelow.
 
PART 5. Signatures and Notary. Complete All Information. Under LRS 35:12, in pertinent part, use “Christian names and surnames of the parties in full and not their initial letters alone or the full
names of the parties and not their initial letters alone, together with the permanent mailing addresses of the parties, and… print or type the full names of the witnesses and of [notaries] under their
respective signatures….[A] full name or a name in full shall include at least one given name and other initials in addition to the surname. It may be any combination of first name and middle initial
 
or initials, if any, and the surname; or the first initial and at least one middle name and the surname; or the complete first and middle name or names and the surname. The notary shall type, print,
or stamp his or her name as it appears on his or her commission.”
 
Witnesses for Principal
BY:
___________________________________________________ ______________________________________________________________________________ ________
 
Principal (Same as Part 2A hereinabove; if TPA, complete “TPA For” below)
Date
 
Print Name: _________________________________________ Print Name: ____________________________________________________________________________
___________________________________________________ Permanent Physical Address: ______________________________________________________________
 
If TPA, TPA For (Same as Part 2B hereinabove):
Print Name: ________________________________________ _______________________________________________________________________________________
 
Subscribed and sworn to before me this _______day of _________________, 200__
___________________________________________
NOTARY PUBLIC
NOTARY
SEAL
Printed Name of Notary ________________________________
Bar Roll or Notary Number_____________ My Commission Expires____________________
Witnesses for Surety
BY:
___________________________________________________ ______________________________________________________________________________ _______
Surety (Same as Part 1D hereinabove)
Date
Print Name: _________________________________________ Print Name: ____________________________________________________________________________
____________________________________________________ Permanent Physical Address: _______________________________________________________________
Print Name: _________________________________________
Subscribed and sworn to before me this _______day of _________________, 200__
___________________________________________
NOTARY
NOTARY PUBLIC
SEAL
Printed Name of Notary ________________________________
Bar Roll or Notary Number_____________ My Commission Expires____________________
____________________________________
If power of attorney used, a copy of the power of attorney or the authorized agent of a surety company must accompany the bond.
Rev. 110209
SURETY BOND FILED WITH THE LOUISIANA DEPARTMENT OF INSURANCE
The text of this official Department of Insurance form is NOT to be altered under penalty of law.
This form is NOT to be used for Bonds for Home Service Contracts
STATE OF ___________________
COUNTY/PARISH OF __________________
PART 1. Bond & Surety. Complete All Information in Part 1, A-D.
A. Bond #
C(1). Describe This Bond (check one):
___Original
B. Bond Issue Date (insert mmddyyyy)
(This may not be the same as the
___Continuation
effective date, but this date must be on
or before the effective date.)
___Other. Specify: ___________________________________________________________________________________________________
C(2). Provide Effective Dates and Times of This Bond [complete all 4 blanks and circle AM or PM for each of C(2)(a) AND C(2)(b)]:
(a)
Effective (mmddyyyy): _________________________ at __________________ AM/PM
(b)
Terminates (mmddyy): _________________________ at __________________ AM/PM
D. Surety Company
1. Name
2. NAIC #
PART 2. Principal & TPA. Complete All Applicable Information in Part 2.
A.
1. Name
2. NAIC #
Principal
B. If TPA, Entity for Which TPA Administers—
1. Legal Name
 
Complete only if LRS 23:1196(C)(1) applicable
2. Physical Address
 
Part 3. Type and Bond Amount. Mark ONLY one type and amount of bond for one year commencing on the date stated hereinabove at Part 1C.
One Hundred Thousand
 
Fifty Thousand
Dollars ($100,000.00)
A. TPA-Bond in
Dollars ($50,000.00)
B. Public Adjuster-
current U.S. Dollars
Bond equal to Fifty
One Hundred Fifty
 
equal to
Thousand current
C. Surety Bond-Bond in
One Hundred
Thousand Dollars
U.S. Dollars
current U.S. Dollars equal to
Thousand Dollars
($150,000.00)
($50,000.00)
($100,000.00)
Two Hundred Fifty
 
Thousand Dollars
($250,000.00)
 
PART 4. KNOW ALL MEN BY THESE PRESENTS, THAT the Principal and Surety, who, after being duly sworn, deposed and said:
THAT they are firmly bound unto the Commissioner of Insurance, State of Louisiana, or his successor in office, under this bond delivered in lieu of deposit of securities conditioned only for and
dedicated exclusively to the prompt payment of all claims arising and accruing to any person by virtue of any policy issued, service agreed to, or fund established by the Principal, for the payment
 
of which the Principal and Surety bind themselves, their heirs, administrators, executors, successors and assigns, jointly and severally, by this agreement;
THAT the condition of this obligation is such that if the above named Principal shall well and faithfully discharge and perform the duties incumbent on him under the provisions of Titles 22 and 23
of the Louisiana Revised Statutes and all other applicable laws, then in such case the above obligation is to become null and void; else to remain in full force, effect and virtue;
 
THAT the provisions under Titles 22 and 23 of the Louisiana Revised Statutes and all other applicable laws for principals, sureties and third party administrators (where third party administrators
are parties) shall be applicable;
THAT this obligation may be continued for any subsequent year by a continuation certificate duly signed and sealed by the Principal and Surety, subject to the terms and conditions of the original
 
bond;
IN WITNESS WHEREOF, Principal and Surety have executed this bond on the dates stated hereinbelow.
 
PART 5. Signatures and Notary. Complete All Information. Under LRS 35:12, in pertinent part, use “Christian names and surnames of the parties in full and not their initial letters alone or the full
names of the parties and not their initial letters alone, together with the permanent mailing addresses of the parties, and… print or type the full names of the witnesses and of [notaries] under their
respective signatures….[A] full name or a name in full shall include at least one given name and other initials in addition to the surname. It may be any combination of first name and middle initial
 
or initials, if any, and the surname; or the first initial and at least one middle name and the surname; or the complete first and middle name or names and the surname. The notary shall type, print,
or stamp his or her name as it appears on his or her commission.”
 
Witnesses for Principal
BY:
___________________________________________________ ______________________________________________________________________________ ________
 
Principal (Same as Part 2A hereinabove; if TPA, complete “TPA For” below)
Date
 
Print Name: _________________________________________ Print Name: ____________________________________________________________________________
___________________________________________________ Permanent Physical Address: ______________________________________________________________
 
If TPA, TPA For (Same as Part 2B hereinabove):
Print Name: ________________________________________ _______________________________________________________________________________________
 
Subscribed and sworn to before me this _______day of _________________, 200__
___________________________________________
NOTARY PUBLIC
NOTARY
SEAL
Printed Name of Notary ________________________________
Bar Roll or Notary Number_____________ My Commission Expires____________________
Witnesses for Surety
BY:
___________________________________________________ ______________________________________________________________________________ _______
Surety (Same as Part 1D hereinabove)
Date
Print Name: _________________________________________ Print Name: ____________________________________________________________________________
____________________________________________________ Permanent Physical Address: _______________________________________________________________
Print Name: _________________________________________
Subscribed and sworn to before me this _______day of _________________, 200__
___________________________________________
NOTARY
NOTARY PUBLIC
SEAL
Printed Name of Notary ________________________________
Bar Roll or Notary Number_____________ My Commission Expires____________________
____________________________________
If power of attorney used, a copy of the power of attorney or the authorized agent of a surety company must accompany the bond.
Rev. 110209