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 cause to be issued, bail bond(s) or undertaking(s) (singularly or collectively the “Bond”) for

(“Defendant”), using power of attorney number(s) (if known)

Rent

Own

Rent

Own

Three

2. PERSONAL DESCRIPTION

U.S. Citizen?

Yes

No

CT Bail Bonds

Defendant Authorization Form

INDEMNITOR APPLICATION AND AGREEMENT

2. PERSONAL DESCRIPTION

3. EMPLOYMENT

4. MARITAL STATUS

5. AUTOMOBILE

6. REFERENCES

REFERENCES (Continued)

7. FINANCIAL STATEMENT/CREDIT INFORMATION

8. NOTES

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