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This is an example of bank indemnity agreement. This document is useful for making bank indemnity agreement.
Application for Title Agents Fidelity and Surety Bonds The Hanover Insurance Company/Massachusetts Bay Insurance Company 440 Lincoln Street, Worcester, MA 01653 Insured Legal Name of Applicant: ______________________________________________________________ Year Established:___________ Tax I.D. Number: ____________________________________________ Street Address:________________________________________________________________________ City: _____________________________________________ State_________ Zip Code: ____________ Contact Name: __________________________ Phone: _________________ Fax: __________________ E-Mail Address: _______________________________________________________________________ Name of Affiliated Interest(s) (i.e. law firm, realtor, builder, mortgage company, etc.) if any: ____________________________________________________________________________________ Form of Organization: Proprietorship____ Partnership____ C or S-Corporation____ LLC____ LP____ Coverage Surety Bond Amount $_________________________ State_____ Have you been declined by another Surety for this Bond?___________ List Owners/ Name(s): _______________________________________________ Percentage Ownership: __________ Stockholders _______________________________________________________ __________ _______________________________________________________ __________ Professional Advisor: Contact: Phone: Advisors Accounting Firm: ______________________________________________________________________ Banking (Escrow): _____________________________________________________________________ Insurance Errors & Omissions Insurance Carrier:_____________________________________________________ Information Term of Coverage: __________________ Limit: $____________________ Deductible: $____________ Internal Are your financial statements: Audited? ____ Reviewed? ____ Compiled?____ Internally prepared? ____ Controls Do checks require two or more signatures? Yes____ No ____ If yes, over what amounts?_____________ Who besides the owners/stockholders can sign escrow checks? (Names and Positions) ____________________________________________________________________________________ Does the person(s) who signs the checks also approve the invoices for payment? Yes ______ No ______ Is there a reconciliation of the bank accounts at least monthly? Yes ______ No ______ Does the person who reconciles the accounts also make deposits or withdraws? Yes ______ No ______ Are electronic funds transfer (EFT) systems utilized? Yes ______ No ______ Who has the power to authorize EFTs? (Names and Positions) ___________________________________________________________________________________ Escrow Do you deposit and disburse funds for closings or settlements? Yes ______ No ______ Account Is a separate file set up a each closing containing the following information: Information Closing instructions? Yes ______ No ______ Documentation of compliance with the instructions including transfers between accounts? Yes___ No__ Are funds received for closings deposited in a trust bank account separate from operating funds and identified as such on bank statements? Yes ______ No ______ Are separate accounting records maintained for each transaction? Yes ______ No ______ Are the escrow of the trust bank accounts reconciled monthly? Yes ______ No ______ How many employees have access to the Escrow Account Funds? ___________ Title Company: Contact: Phone: Date of last Audit: Companies ____________________________________________________________________________________ Represented ____________________________________________________________________________________ ____________________________________________________________________________________ Fidelity Coverage Form A – Employee Dishonesty Data Total Employees: _______ Number of Officers: _______ Number of employees who handle, have custody of money, or are directly or indirectly responsible for controlling records of money, securities or other property: _______ Losses Have you sustained any employee dishonesty losses in the past three years? Yes_______ No ______ If yes, please explain in a separate attachment. (1) AGREEMENT OF INDEMNITY WHEREAS, at the request of the undersigned (hereafter referred to as “Indemnitors”), and upon the condition precedent that this Agreement be executed, The Hanover Insurance Company and/or Massachusetts Bay Insurance Company, 100 North Parkway, Worcester, Massachusetts 01605 (hereafter individually and collectively referred to as “Surety”), has executed, or may in its discretion hereafter execute certain surety contracts (hereafter referred to as “bonds”) on behalf of any one or more of the Indemnitors, in which bonds the Indemnitors hereby affirm they have a substantial, material and beneficial interest. NOW THEREFORE, in consideration of the execution, continuance or extension of such bonds, the Indemnitors, jointly and severally, agree in favor of the Surety as follows. 1. The Indemnitors shall exonerate, indemnify, and save harmless the Surety from and against all loss, cost and expense which the Surety may pay or incur, including, but not limited to, interest, court costs and attorney fees resulting from its having executed or procured the execution of the bonds, or in enforcing the Indemnitor’s obligations under the terms of this Agreement. The Indemnitors will promptly pay to the Surety all premiums for such bonds, and will continue to pay the same where such bonds are continued, until the Indemnitors shall serve evidence satisfactory to the Surety of its bond discharge or release. 2. Payment shall be made to the Surety by the Indemnitors as soon as liability exists or is asserted against the Surety, whether or not the Surety shall have made any payment therefor, in an amount deemed necessary by the Surety to indemnify it from any loss, cost, or expense. The Surety may adjust, settle or compromise any claim, suit, or other proceeding arising out of any bond against the Surety and/or any Indemnitor. In the event of any payment by the Surety, the Indemnitors agree to immediately reimburse the Surety for any and all payments made under the Surety’s belief that liability for the payment existed or that payment was necessary or expedient, whether or not such liability, necessity, or expediency existed. Vouchers or other evidence of payment by the Surety shall be prima facie evidence of the fact and amount of such liability, necessity, or expediency and of the Indemnitors’ liability to the Surety therefor. 3. The Indemnitors hereby authorize the Surety or its authorized agent to make any inquiry which it deems necessary of any financial or credit institutions, persons, firms, and corporations in order to obtain all information relating to the Indemnitors’ payment history and credit status in order to verify or obtain information concerning the Indemnitors’ credit history or any other information submitted in connection with the application for bonds. The Surety may decline to execute any bond without impairing the validity of this Agreement, and the Indemnitors agree not to make claim against the Surety due to its refusal or failure to so execute. 4. This Agreement applies to bonds written by the Surety on behalf of the Indemnitors and any of their wholly or partially owned subsidiary companies, subsidiaries of subsidiaries, divisions or affiliates, partnerships, joint ventures or co- ventures in which any of the Indemnitors, their wholly or partially owned subsidiary companies, subsidiaries of subsidiaries, divisions or affiliates have an interest or participation, whether open or silent; jointly, severally, or in combination with each other; now in existence or which may thereafter be created or acquired. Applicable in New York State - 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. IN WITNESS WHEREOF, the Indemnitors have executed or have caused the Agreement to be duly executed by their authorized representatives on the ______ day of ___________________, in the year of _________. ___________________________________ _______________________________________ Witness to Individual or Proprietorship Individual and Proprietorship applicant sign here __________________________________________ (seal) Name of Corporation or Partnership applicant typed or printed here ______________________________________ ______________________________________ Attest by Corporate Officer or Witness to Partner signature Corporate Officer or Partner sign here Third Party Indemnitor(s) sign below: In Consideration of The Hanover Insurance Company / Massachusetts Bay Insurance Company executing the bond(s) hereinabove applied for, we jointly and severally join in the foregoing indemnity agreement. __________________________________ ________________________________________________ Witness Indemnitor – Include Social Security # / Tax ID # ( ) Residence Address: __________________________________ ________________________________________________ Witness Indemnitor – Include Social Security # / Tax ID # ( ) Residence Address: (2) __________________________________ ________________________________________________ Witness Indemnitor – Include Social Security # / Tax ID # ( ) Residence Address: __________________________________ ________________________________________________ Witness Indemnitor – Include Social Security # / Tax ID # ( ) Residence Address: (3)
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