New Jersey (NJ) Fire Alarm, Burglar Alarm & Locksmith Bond Application

James C. Franchino Agency, Inc.
PO Box 36, Florham Park, NJ 07932-0036
Phone: 973-377-6100

Note: Please PRINT this blank application, fill it out completely, and MAIL it to the agency with payment. Please do not fax this form to us. Application must be accompanied by a check (check does NOT have to be certified) or money order for $75.00 (Seventy Five Dollars) made out to: James C. Franchino Agency Inc.

  TERM OF THE BOND:  When received until January 31, 2011.
COST OF THIS BOND: $75. Seventy Five Dollars for the term.

The bond will be issued in the name of the business.  Please make sure the business name you write below is the same that appears on your license.

BUSINESS NAME to appear on  the bond (same as your business license): ____________________________________________________________________________________

Owner(s) personal name:________________________________________________________________

Street: _______________________________________________________________________________

City: ______________________________ County : ____________________

State: _________________ Zip: ____________

When doing the required background check on your employees, have any been convicted of a crime?  Yes / No

Amount of General Liability your business currently carries: $500,000.,  $1,000,000., no coverage,
other: _______________________________________________________________________________

License number, (if renewal): __________________________

License type: (please circle) Fire,  Burglar,  Locksmith

Business Federal Tax ID #: _______________________________

Social Security # of owner: _________________________________

Business phone # (                  ) _________________________________

Home phone # (              ) ______________________________________

Cell # (              ) ______________________________________________

Email address: _______________________________________________________________________
(please print email address neatly)

Name and City of the AGENCY that currently writes your general liability insurance:

___________________________________________________________________________________

Name of the INSURANCE AGENCY that currently writes your general liability insurance:

_____________________________________________________________________________________

Expiration date of your current policy: ______________________________________________________

Below find general fraud statement that needs to be signed. This statement is required by the NJ Dept. of Insurance for all new policies. General Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance 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 the person to criminal and civil penalties.

Signature: ______________________________________________ Date: ___________________