Cumberland Surety, Inc.
367 W. Short St., Lexington, KY 40507 1-(859) 254-8622
P a g e 1
1. Name of firm:
3. Phone: ( )
Fax: ( ) Contact Person:
4. Year Business Started:
5. Fiscal Year End:
6. Business Type:
Limited Liability Company
0 “S” Corporation
0 Other, Describe
7. State of Incorporation:
8. Area of Operation:
9. % of work done as prime contractor?
% of work done as subcontractor?
10. % of work done for governmental agencies?
% of work done for private ow
11. What % of work is bonded compared to annual earned revenue?
Description of types of work performed:
List corporate officers, partners or proprietors of the firm:
Social Security #
Date of Birth
14. Will all of the above individuals and their spouses personally indemnify the Surety Company?
If no, please provide a written explanation and attach to this application.
Is there an existing, formal buy-sell agreement among the owners of the firm?
If yes, is it funded by life insurance?
Please attach a summary of
Does the firm have a formal business plan?
If yes, please attach to
If any person knowingly (and with intent to injure, defraud or deceive, any insurance company or other person) files an applicat
materially false information; or, if any person conceals (so as to mislead) information concerning any fact material to an insurance a
has committed a fraudulent insurance act, which is a crime.
I authorize Cumberland Surety to perform ongoing checks of credit, banking and business references along with site inspections of o
references to provide such information on the company and its principals, It is understood that the information provided here is true
best of my knowledge.
Name of Spouse
ion for insurance cont