Notary Bond InsurancePlease complete the form below. We will be in contact with you shortly.Notary Bond Insurance Form Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Middle Last Suffix Please type exactly as it appears on your notary commission.Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Billing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Cell Phone*Can we communicate with you over text?*YesNoDate of Birth* Date Format: MM slash DD slash YYYY Driver's License #*Employer Name*Occupation*PositionWork Phone*Notary Bond Expiration Date*County Commissioned*Please choose your desired Errors & Omissions coverage limit*$25,000 - $134.50$50,000 - $216.00$100,000 - $424.00PLEASE READ CAREFULLY. Credit-based Insurance Loss Evaluation Score Disclosure. Important Consumer Information. Insurance companies use insurance scoring as part of its criteria to determine the rate you are charged for insurance. A report will be ordered on you and the resulting loss evaluation score may be used as additional criteria for rating purposes. Information about you and your credit history, such as your bill-paying history, the number and type of accounts with late payments, any collection actions, current outstanding debt as well as the age of your accounts is collected from your credit report to determine your loss evaluation score. A scoring system, which is provided to us and our insurance carriers by a third party, awards points based on each factor and computes a score. Part of this score is based on statistical information which compares information from your credit performance with those of consumers with similar profiles. Insurance carriers only use this information in helping them determine what rate you are charged for insurance. The information is not released without your permission and is kept confidential. Insurance companies are prohibited from using credit history or insurance scores based wholly or in part on residence, sex, race, color, creed, occupation, income, physical handicap or disability of an applicant or insured. Credit history or insurance scores also cannot be used arbitrarily, capriciously, or for any unfairly discriminatory reason. You should be aware of the information maintained in your credit report and it is in your best interest to check your report for accuracy. You can obtain a report from each of the three major credit report providers once annually without charge. You can obtain this report online at www.annualcreditreport.com, by telephone by calling 877-322-8228 or via regular mail by completing a request form found at www.ftc.org and mailing the form to Annual Credit Report Request Service PO Box 105281 Atlanta, GA 30348-5281. You should review your reports carefully and dispute any incorrect information directly with the provider of the report.* I have Read and Agreed to the Terms Above
