INDEMNITOR APPLICATION

INDEMNITOR APPLICATION AND AGREEMENT

You, the undersigned Indemnitor (“Indemnitor” or “you”), hereby represent and warrant that the following declarations made and answers given are true, complete and correct and are made for the purpose of inducing Bankers Insurance Company (“Surety”) to issue, or caused to be isssued, bail bond(s) or undertaking(s) (singularly or collectively the “Bond”) for (“Defendant”), using power of attorney number(s) (if known) , in the total amount of Dollars($ ) in the Court of .
1. INDEMNITOR NAME AND ADDRESS









Rent orOwn?



Rent orOwn?


PERSONAL DESCRIPTION









YesNo









3. EMPLOYMENT







4. MARITAL STATUS/CHILDREN:









YesNo



5. AUTOMOBILE









6. REFERENCES






















7. FINANCIAL STATEMENT/CREDIT INFORMATION







9.NOTES
THIS INDEMNITY AGREEMENT (“Agreement”) is entered into between you, the undersigned Indemnitor, and Surety through
Surety’s duly appointed independent bail producer referenced below (“Producer”).
1. You will have Defendant appear in any court required in connection with the bond(s) at the times stated in the bond(s) and all
other times as may be ordered by the court.
2. You, jointly and severally (together and separately) with any other Indemnitor, shall indemnify the Surety and keep the
Surety indemnified and hold it harmless from and against any and all losses, demands, liabilities, fees and expenses
relating to, or arising out of, Surety’s issuance or procurement of the Bond, including, but not limited to the following:
(a) the principal amount of any forfeiture of, or judgment on, the Bond, plus any related court costs, interest and legal
fees incurred, (b) a fugitive recovery fee if there is a forfeiture of the Bond (which fee is typically ten percent of the
amount of the Bond for an in-state recovery, plus any out of pocket expenses) (c) any and all extradition costs that may
be incurred to apprehend and return the Defendant, and (d) if a collection action is required, reasonable and actual
attorneys’ fees plus any and all other costs, expenses and/or assessments that may be incurred as a result of any
forfeiture of the Bond subject to applicable law (if any) as stated in an attached addendum. The voucher, check or other
evidence of any payment made by Surety or Producer, by reason of such Suretyship, shall be conclusive evidence of
such payment in any lawsuit against you both as to the propriety of such payment and as to the extent of your liability to
Surety for such payment. Further, you will, upon demand, place with Surety the requisite funds to meet any such claim,
demand, liability, attorneys’ fees, expense or judgment, whether that demand is made before or after Surety has paid or
advanced such funds.
3. Subject to applicable law (if any) as stated in an attached addendum: (a) any property or collateral you deposit is deposited as
security for the payment of any and all monies and sums due to Surety or Producer, including all liability, demands, damages,
judgments, interest, attorneys’ fees and costs suffered, sustained, made or incurred by Surety or Producer on account of, arising
out of or relating to the Bond and transactions contemplated thereby (including, without limitation, the items referenced in
paragraph 2 above), your failure to comply with the terms and conditions of this Agreement, and any and all debt or other
obligations arising out of or evidenced by any agreement executed by Defendant, you or any other Indemnitor for the benefit of
Surety or Producer (“Liabilities”); and (b) if you grant the Surety a lien or a security interest in any property or collateral to
enforce the obligations contained in this Agreement, and if you do not perform all of your obligations in this Agreement, you
authorize the Surety to (i) apply or sell any collateral security you deposited to reimburse the Surety for any and all Liabilities
of any kind or nature, (ii) hold, apply or sell the collateral, or any part thereof, to protect or reimburse the Surety by reason of
the execution at any time of any other bond for or on behalf of you or Defendant, and (iii) apply and sell the collateral for the
purpose of placing the Surety in cash funds or protecting the Surety against any claim, demand or loss under the Bond or any
other bond executed on your or Defendant’s behalf. Subject to applicable law (if any) as stated in an attached addendum, the
Surety may make any such sale, at its discretion, at public or private sales, and without demand, notice or advertisement of the
time and place of said sale, and also with the right to purchase said collateral at such sale or sales, freed and discharged from
any equity or redemption.
4. The Surety shall not be liable for the depreciation of any collateral or for any interest thereon. In the event of depreciation of
the collateral, or any part thereof, or of any collateral which may be hereafter deposited with the Surety for its protection, upon
request of the Surety, you shall provide the Surety with additional and satisfactory collateral so that the total market value of the
collateral shall, at all times, be equal to the market value of the collateral at the time of its initial deposit. Subject to applicable
law (if any) as stated in an attached addendum, if you fail to deposit such additional collateral, the Surety shall have the full
right, power and authority, without further demand or notice, to sell, assign and deliver the whole or any part of such collateral,
substituted collateral, or additional collateral, at public or private sale, at its option, and without demand, notice or
advertisement, and also with the right to purchase said collateral at any such sale, freed and discharged from any equity or
redemption.

5. If a confession of judgment is taken in connection with the Bond, the Surety shall have the right to enter and file the same at
any time, and such judgment shall be a lien and entitled to a preference against any of your property, whether or not the Surety
is indemnified at the time of the filing or entry of such judgment. In case a confession of judgment is filed by the Surety
against you, the judgment entered shall be effective and available to the Surety against you not only in connection with the
Bond but also in connection with any other bond that may have been written by the Surety in which you are either the
Indemnitor or defendant.
6. You acknowledge and agree that the Surety may foreclose any or all of the liens and security interests arising out of the
transactions relating to the Bond or this Agreement, or exercise any of its rights or remedies under this Agreement, or take any
combination of such actions, without waiving any other right or remedy. Failure to exercise any rights or remedies of the
Surety at any one time shall not constitute a waiver of the right to exercise them at any other time. Any security or collateral
you give may be substituted, subordinated, or released by the Surety without affecting any other rights. The Surety shall not be
obligated to enforce its rights against any security or collateral prior to enforcing its rights against you or any other Indemnitor.
7. Subject to applicable law (if any) as stated in an attached addendum, the Surety will return the collateral to you when all of the
following are satisfied: (i) the Surety receives competent written legal evidence satisfactory to the Surety (for example, written
notice from the court) of the Surety’s discharge or release from all liability under the Bond; (ii) there are no outstanding
Liabilities of any kind arising out of or relating to the Bond; (iii) there are no other outstanding bonds or obligations executed
by, for or on behalf of you or Defendant in connection with which the Surety may deem it advisable to retain such collateral for
its protection; and (iv) upon the Surety’s request, you shall have executed and delivered to the Surety a general release upon the
Surety’s return of the collateral to you. If the Surety deems it necessary to make any outlay to protect any collateral or security
in its possession, whether the same be real or personal property, you authorize the Surety to do so, and you agree to indemnify
and reimburse the Surety for any such outlay as in the judgment of the Surety may be necessary to protect its collateral or
security, including payment of taxes or liens or mortgages and any attorneys’ fees or service fees for time spent and/or special
services rendered.
8. The Surety shall have the right to transfer and/or assign, in whole or in part, its rights and obligations in this Agreement, and/or
in the Bond to the Producer or any other person or entity (“Assignee”) without notice to or consent from you. Subject to any
limitations imposed upon Assignee by the Surety, Assignee shall have the right to enforce in any action, proceeding or
otherwise any of the Surety’s rights herein or arising out of any of the transactions contemplated hereby, and you shall not, and
expressly waive any right to, assert the claim or defense that Assignee does not have the right to enforce such rights in any such
action, proceeding or otherwise. If more than one bond is made or has been made for the Defendant, then this Agreement shall
extend to and cover all those bonds and the terms of this Agreement shall apply to each bond individually or as a group.
9. This Agreement and all documents that are executed in connection with this Agreement set forth all the terms of the agreement
between the Surety and you. All statements, representations, promises, agreements, and affirmations made by the Surety and its
producers and employees prior to or contemporaneously with the execution of this Agreement are contained within this
document, and unless they are specifically set forth in this Agreement are of no force or effect whatsoever in determining the
rights and liabilities of the Surety and you. You further agree to execute and be bound by any other future documents necessary
to carry out and effectuate this Agreement.
10. You hereby acknowledge and agree that neither the Surety nor its Producer has recommended or suggested any specific
attorney or firm of attorneys to represent the Defendant in any capacity.
11. This Agreement may not be terminated or modified orally. All modifications and terminations of this Agreement, including
any release of your liability hereunder, must be in writing and signed by the Surety and you.
12. To the maximum extent permitted by applicable law, you hereby waive any and all rights you may have under federal law
(including, but not limited to, Title 28 Privacy Act-Freedom of Information Act, Title 6, Fair Credit Reporting Act) and any
local or State law relating to Surety’s obtaining, and you consent to and authorize Surety to obtain, any and all private or public
information and/or records concerning you from any party or agency, private or governmental (local, state, federal), including,
but not limited to, credit reports, Social Security Records, criminal records, civil records, driving records, tax records, telephone
records, medical records, school records, worker compensation records, and employment records. You further authorize,
without reservation, any party or agency, private or governmental (local, state, federal), contacted by Surety to furnish in
accordance with applicable law any and all private and public information and records in their possession concerning you to the
Surety and direct that a copy of this document shall serve as evidence of said authorization. You irrevocably grant to surety
and its producers, agents and representatives the right to enter your residence or other property owned or occupied by you or
Defendant without notice, at any time, for the purpose of locating, arresting, and returning to custody the Defendant, and
subject to applicable law, you waive any and all causes of action in connection therewith including, without limitation, torts of
trespass and false imprisonment.
13. You agree that Surety may attach a location tracking device on any vehicle owned or driven by you, at any time, without notice,
and monitor the location of the vehicle through any available technology. You further agree that Surety may use location
technologies to locate your wireless device at any time during the period of Defendant’s bail and any applicable remission
period, and the Bond is conditioned upon your full compliance with the following terms and conditions: (a) Surety, at its
discretion, will use network-based location technologies to find you; (b) this is the only notice you will receive for the
collection of your location information; (c) Surety will retain location data only while the Bond is in force and during any
applicable remission period; (d) Surety will disclose location information only to the courts as required by court order; (e)
Surety and its licensed producers, designees and representatives will be the only persons with access to your location
information; (f) YOU WILL NOT HAVE THE OPTION TO OPT-OUT OF LOCATION USE OR TRACKING DURING
THE BAIL PERIOD; and (g) all questions relating to location capability should be directed to Surety

14. In the event any provision herein shall be deemed to exceed any applicable state or federal law, then such provision shall
automatically be deemed to have been revised to comply with such law so as to provide the Surety with the maximum
protection from any loss or liability. The invalidity or unenforceability of any provision herein (or portion thereof) shall in no
way effect the validity or enforceability of any other provision (or portion thereof).
15. You have not been paid to sign this Agreement. You have read the above contract, understand it and agree to fulfill ALL of the
provisions therein.

IMPORTANT FRAUD WARNINGS

ALABAMA RESIDENTS

-Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

ARKANSAS RESIDENTS

- Any person who knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

FLORIDA RESIDENTS

- Any person who knowingly or with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

LOUISIANA, RHODE ISLAND & WEST VIRGINIA RESIDENTS

- Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.

MAINE, TENNESSEE, VIRGINIA & WASHINGTON RESIDENTS

- It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.

MARYLAND RESIDENTS

- Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

NEW JERSEY RESIDENTS

- Any person who includes any false or misleading information on an application for an
insurance policy is subject to criminal and civil penalties.

NEW MEXICO RESIDENTS- ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM
FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND
CRIMINAL PENALTIES.
NEW YORK RESIDENTS

- Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each
such violation.

OHIO RESIDENTS

- Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA RESIDENTS - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is
guilty of a felony.

PENNSYLVANNIA RESIDENTS

- Any person who knowingly and with intent to defraud any insurance company or other
person files an application for insurance or statement of claim containing any materially false information or conceals for the
purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
SIGNED, SEALEDAND DELIVERED at , this day of , 20 .
WITNESS INDEMNITOR
Sign: Sign:
Print: Print:

SURETY:
Bankers Insurance Company
11101 Roosevelt Blvd. N.
St. Petersburg, FL 33716
800-627-0000
BAIL PRODUCER: [stamp must include name, address, phone no. and license no.]