Broker Application

1. You must answer the following questions accurately.

2. There is no cost should you decline the offer, obtaining a quote is 100% free.

3. I understand false statements may result in forfeiture of benefits and possible prosecution by the US Attorney-General - (Any person who knowingly and with the intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing false, or misleading information is guilty of a felony of the third degree.

4. The quote you are about to receive is only a conditional offer and is subject to change based on a multitude of considerations.

5. The quote may include a broker fee. Any possible broker fees are part of the quote you are about to receive.

6. If your bond is cancelled mid term, the fees and all premiums are fully earned, and are not refundable. In addition, fees may earn interest. This undeclared income is non-refundable and fully earned as well as any fees charged.

7. JW Bond Consultants, Inc. reserves the right to change the terms of this agreement at anytime without notice.

8. I agree that I will not take over any bonds issued by JW Bond Consultants, Inc. by broker of record for a minimum of 3 renewal terms.

9. This agreement shall serve as the writing required pursuant to the rules set forth by your Department of Insurance.