Smalley Insurance Agency, Inc.
Smalley Insurance Agency, Inc.

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Dealer Bond - Credit Consent Release

The undersigned applicant(s) and or Indemnitor(s) understand and agree that by submitting an application to any of the writing companies of CNA Surety Corporations, the undersigned authorize the verification of information provided and the obtaining of additional information from any source, including obtaining a credit report on the undersigned and/or any other individuals associated with the business involved, including spouses, at the time of application, in any review or renewal, at the time of any potential or actual claims, or for any other legitimate purpose determined by the writing company in its reasonable discretion.

Signed this _____ day of ______________, ______


Printed name ______________________________

Signature _________________________________

Social Security # ___________________________

Home Address _____________________________


FEIN # ___________________________________

Approximate Worth $ _______________________

Homeowner:  Yes ___    No ___

Married:  Yes ___    No___

Bond Effective Requested Date: _______________

Name of business to be shown on bond:


         (Must match exactly the name on license)


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