Bankers Insurance Company Confidential Application (All questions must be answered in full) I the undersigned do hereby apply to the BANKERS INSURANCE COMPANY to act as my bail in the amount of $ In the court of wherein I am charged with and and I agree to the following terms and conditions prescribed by the State Insurance Department.

TERMS AND CONDITIONS The following terms and conditions are an integral part of this application for appearance bond No. dated for which BANKERS INSURANCE COMPANY or its Agent shall receive a premium in the amount of ($ ) Dollars, and the parties agree that said appearance bond is conditioned upon full compliance of all said terms and conditions and is a part of said bond and application therefore. 1. BANKERS INSURANCE COMPANY, as bail, shall have control and jurisdiction over the Defendant during the term for which the bond is executed

and shall have the right to apprehend, arrest and surrender the Defendant to the proper officials at any time as provided by law. 2. in the event surrender of Defendant is made prior to the time set for Defendant’s appearances, and for reason other than as enumerated below in

paragraph 3, then Defendant shall be entitled to a refund of the bond premium. 3. It is understood and agreed that the happening of any one of the following events shall constitute a breach of Defendant’s obligation to BANKERS

INSURANCE COMPANY hereunder, and BANKERS INSURANCE COMPANY shall have the right to forthwith apprehend, arrest, and surrender Defendant, and Defendant shall have no right to any refund of premium whatsoever. Said events which shall constitute a breach of Defendant’s obligation hereunder are: a. The defendant or co-signer providing materially false information on bail bond; b. The court’s increasing the amount of bail beyond sound underwriting criteria employed by the bail bond agent or bail bond surety; c. A material and detrimental change in the collateral posted by the defendant or one acting on the defendant’s behalf; d. The defendant changes their address or telephone number employer without giving reasonable notice to the bail bond agent or bail bond surety; e. The defendant is arrested for another crime, other than a minor traffic violation, while on bail; f. The defendant is back in jail in any jurisdiction and revocations can be served prior to the defendant being released; g. Failure by the defendant to appear in court at any appointed times; h. Finding of guilt against the defendant by a court of competent jurisdiction; i. A request by the co-signer based on reasons (a) through (h) pertain to the defendant: items (a), (c), (e), (g) and (i) pertain to co-signer, if any.

1. NAME AND ADDRESS

Full name Home phone Nickname or alias Neighbor phone Current address

Street City State Zip

Mailing address P.O. Box/Street City State Zip

2. PERSONAL DESCRIPTION/MARKS Weight Height Race Sex Male Female Color of eyes Color of hair Date of Birth Nationality Citizenship status Place of birth Scars, marks

3. MARITAL STATUS/CHILDREN Married Divorced Separated Widowed Single Cohab Spouse’s name Spouse’s occupation Spouse’s employer Phone Spouse’s Date of Birth Driver’s license # Social Security # Child’s name Age School attended Child’s name Age School attended Child’s name Age Occupation Child’s address

Street City State Zip

4. EMPLOYMENT Your occupation Name of Company Business Phone Name of supervisor Address How long have you worked for this Co.? Former employer(s)

5. SS#/DL#/CAR/CREDIT REFERENCES Social Security # Driver’s License # State Describe Car: Year Make Model Color Tag No. Describe Car: Year Make Model Color Tag No. Where financed? Amount Owed: $ Bank references Credit card name and acct # Credit card name and acct # Credit card name and acct #

For good and valuable consideration, the undersigned principal hereby agrees to indemnify and/or hold harmless BANKERS INSURANCE COMPANY or its Agent for any and all losses not otherwise prohibited by law, or rules and regulations promulgated under any applicable statute. In addition, the Defendant hereby authorizes and directs his relatives, employers, bankers, the Federal Social Security Administration, the Internal Revenue, the state Department of Disability Insurance, the United States Armed Forces, the state Division of Motor Vehicles, all Municipal, County, State and Federal Law Enforcement Agencies and any other persons or organizations having information concerning the Defendant’s whereabouts to give such information to BANKERS INSURANCE COMPANY and its assigns and/or duly authorized representatives. The Defendant understands that any information obtained will be used for the purpose of securing his or her appearance and/or apprehension for Court appearance, and for the purpose of securing reimbursement for any expenses incurred as a result of Defendant’s non-appearance. The Defendant hereby waives his or her right with respect to the Privacy Act and authorizes the use of copies of this document by BANKERS INSURANCE COMPANY and its assigns and/or duly authorized representatives. Signed sealed and delivered this day of Signature of Applicant _________________________________________ Mailing address ____________________________________________

BIC4320 680104

AGENT NAME, ADDRESS & PHONE

6. MORTGAGE/LANDLORD/RESIDENCE INFORMATIONHow long have you lived at your current address? Do you Own Rent your home? Other

Mortgage Company or Person from whom you rent Address of Mortgage Company or Landlord

7. ATTORNEYFull name Address Phone

8. LIST REFERENCES (Relatives and Personal Friends) WHO DO NOT LIVE AT THE SAME ADDRESSName Address Phone

Relation Employer Job Phone Name Address Phone

Relation Employer Job Phone Name Address Phone

Relation Employer Job Phone Name Address Phone

Relation Employer Job Phone Name Address Phone

Relation Employer Job Phone Name Address Phone

Relation Employer Job Phone

9. ADDITIONAL INFORMATIONReason for arrest DATE OF ARREST Case Number(s): List all previous arrests Bonded before by Still indebted

INDEMNITY AGREEMENT

RELATIONSHIP TRUE NAME DOB

ADDRESS APT. #

CITY STATE ZIPCODE Buying Renting

HOME PHONE WORK PHONE CELL PHONE

OCCUPATION EMPLOYED BY HOW LONG?

EMPLOYER'S ADDRESS CITY STATE ZIP CODE

SS# DRIVERS'S LICENSE #

NAME OF SPOUSE DRIVERS'S LICENSE # S.S.# DOB

SPOUSE'S EMPLOYER HOW LONG?

ADDRESS CITY WORK #

REFERENCE ADDRESS PHONE

WHEREAS, Bankers Insurance Company, a Florida Corporation (hereinafter called the SURETY) at the request of the undersigned, and upon the security

hereof, has, or is about to become SURETY on an appearance bond for

in the sum of Dollars by its certain bond or undertaking, a copy of which is attached hereto and made a part hereof:

NOW THEREFORE, in consideration of the premises and the sum of one dollar in hand paid, receipt whereof by each of us is hereby acknowledged, theundersigned do/does hereby undertake, agree and bind themselves, their representatives, successors and assigns, as follows:

1. That the undersigned will have the aforesaid forthcoming beforethe court named in said bond, attached hereto, at the time therein fixed, and from day to day and term to term thereafter, as may be ordered by the said court.

2. That the undersigned will at all times indemnity and save SURETY or its Agent, harmless from and against every and all claims, demands, liability, cost, charge,counsel fee, expense, suit order, judgment or adjudication whatsoever which the said SURETY or its Agent shall or may for any cause at any time sustain or incurby reason or in consequence of the said SURETY having executed said bond or undertaking, will upon demand, place the said SURETY or its Agent in funds tomeet every claim, demand, liability, cost, charge, counsel fee, expense, suit order, judgment, or adjudication against it, by reason of such Suretyship, and before itor its Agent shall be required to pay the same.

3. The condition of said Indemnity Agreement provides that as long as there is any liability or loss of any nature whatsoever to the SURETY upon the bond referredto herein, the undersigned will not make any transfer, or any attempted transfer of any of the property, real or personal given as security or which the undersignedmay subsequently acquire or any interest therein, and it is further agreed that the SURETY or its Agent shall have a lien upon all property of the undersigned forany sums due it for which it has become, or may become, liable by reason of its having executed the bond referred to herein.

4. The voucher or any other evidence of any payment made by the said SURETY or its Agent, by reason of such Suretyship, shall be conclusive evidence of suchpayment against the undersigned and the undersigned's estate both as to the property thereof and as to the extent of the liability thereof to the said SURETY.

5. That the said SURETY or its Agent, may withdraw from its Suretyship upon said bond or undertaking at any time that it may see fit, as provided by law.

6. That the Agreement shall not be returned by the said SURETY or its Agent, at the time it shall be satisfied of the termination of its liability under said bond orobligation, but shall be retained.

7. That the failure of any of the undersigned to comply with the provisions of this Indemnity Agreement shall be binding upon the others.

8. If any provision or provisions of this instrument be void or unenforceable under the laws of any place governing its construction or enforcement, this instrumentshall be void and vitiated thereby but shall be construed and endorsed with the same effect as though such provision or provisions were omitted.

9. Indemnitor(s), hereby authorize any person, agency, partnership, or corporation having any information concerning my character and financial reputation torelease such information to Bankers Insurance Company, its assigns and/or duly authorized representatives. I hereby release such person, agency, partnership, orcorporation from liability which may be incurred in releasing this information to Bankers Insurance Company, its assigns and/or duly authorized representatives.

10. I hereby waive any and all rights I may have under Title 28 Privacy Act Freedom of Information Act, Title 6, Fair Credit Reporting Act, and any such local orState law. I Consent to and authorize Bankers Insurance Company, and/or its Agent, to obtain any and all private or Public information and/or records concerningme from any party or agency, private or government (local, State, Federal), including, but not limited to, Social Security Records, criminal records, civil records,driving records, telephone records, medical records, school records, workers' compensation records, employment records. I authorize without reservation, anyparty or agency, private or government (local, State, Federal), contacted by Bankers Insurance Company, and/or its Agent, to furnish any and all private and publicinformation and records in their possession concerning me to Bankers Insurance Company, and/or its Agent.

For good and valuable consideration, the undersigned principal agrees to indemnify and hold harmless the surety company or its agent for all losses not otherwise

prohibited by law or by rules of the Department of Insurance.

Witness Indemnitor

Witness Indemnitor

IN WITNESS WHEREOF, the undersigned have duly executed these presents this day of ,

(L.S.)

(L.S.)

BIC9920080505

INSURANCE GROUP

AGENT NAME, ADDRESS & PHONE Bankers Insurance Company DISCLOSURE NOTICE

CONDITIONS OF BOND:

Defendant

Co-Signer

Court

Charge

Bond Amount $

Bond Number

1. The SURETY, as bail, shall have control and jurisdiction over the principal during the term for which the bond is executed and shallhave the right to apprehend, arrest and surrender the principal to the proper officials at any time as provided by law.

2. In the event surrender of principal is made prior to the time set for principal's appearances, and for reason other than a "good cause"as enumerated below in paragraph 3, then payee shall be entitled to a refund of the bond premium.

INITIAL FEES NON-REFUNDABLE Bond Premium, Maximum: (no more than 20%) Minimum: (not less than 10% of bond) $ Document Preparation (not to exceed $20 per set of bond forms) $ Credit Card Fee (not to exceed 5% of amount charged to credit card) $

Total Initial Fees $ ADDITIONAL FEES 1. Limited to actual and reasonable expenses required because the defendant fails to appear before the court at any designated times, or fails to comply with

the court order, or fails to comply with the terms of the bail bond agreement or any promissory notes pertaining to that agreement. The following are some reasonable expense fees: i. reasonable expense fee for mileage is IRS mileage reimbursement standard for business miles;ii. reasonable apprehension expense fees include meals at mid-range restaurants, lodging at mid-range hotels, transportation at no more than coach fares;

and iii. reasonable collateral expense fees: actual expenses to obtain collateral and, actual storage expenses, if collateral is in a secured storage area.

2. A late payment fee of $20 or 5% of the delinquent periodic payment whichever is less.3. If a fee is charged by the court or the jail to process a bail bond, the actual fee charged may be passed through to the defendant or the co-

signer. _________GROUNDS FOR REVOCATION

It is understood and agreed that the happening of any one of the following events shall constitute a breach of principal's obligation to theSURETY hereunder, and the SURETY shall have the right to forthwith apprehend, arrest and surrender principal, and principal shall have noright to any refund of premium whatsoever. Should the defendant violate any of the following, the defendant shall be subject to immediatebond revocation and the defendant, or the co-signer, or both shall be subject to all costs incurred to return the defendant to the court.Grounds for revocation include the following:

(a) The defendant or co-signer providing materially false information on bail bond application; (b) The court's increasing the amount of bail beyond sound underwriting criteria employed by the bail bond agent or bail bond surety; (c) A material and detrimental change in the collateral posted by the defendant or on acting on the defendant's behalf; (d) The defendant changes their address or telephone number or employer without giving reasonable notice to the bail bond agent or bail bond surety; (e) The defendant is arrested for another crime, other than a minor traffic violation, while on bail; (f) The defendant is back in jail in any jurisdiction and revocations can be served prior to the defendant being released; (g) Failure by the defendant to appear in court at any appointed times; (h) Finding of guilt against the defendant by a court of competent jurisdiction; (i) A request by the co-signer based on reasons (a) through (h) above. Items (a) through (h) pertain to the defendant; items (a), (c), (e), (g) and (i)

pertain to co-signers, if any.

COLLATERAL The following has been given as collateral to guarantee all court appearances of the defendant until the bond is exonerated:

The following has been given as collateral to guarantee payment of bond fees:

In the event judgement is entered against the surety or the bonding fee is not paid according to the terms of the bail bond agreement and its promissory note, if any, following written notice to the undersigned of such judgement or non-payment, the undersigned authorize /Bankers Insurance Co. to convert the appropriate collateral to collect the judgement or the unpaid bond fees. Should proceeds from the sale of the collateral be insufficient to cover the outstanding balance due, the defendant, the co-signer, or both, agree to be personally liable for the difference. Should the proceeds for the sale exceed the balance, the difference will be returned to the depositor of the collateral. The depositor's signature below constitutes acknowledgment of a Bill of Sale for the collateral. The depositor accepts this agreement as a bill of sale for the collateral. By signing below I certify that I have read and understand this disclosure form, the bail bond agreement and its attached promissory note, if any. I certify under penalty of perjury that all the information given to /Bankers Insurance Co. verbally and in writing on all documents relevant to this bond are true and accurate. The co-signer agrees that should the co-signer request /Bankers Insurance Co. to revoke the defendant's bond, with or without probable cause, the co-signer will be responsible to pay /Bankers Insurance Co. and their agents for the time returning the defendant to jail at the rates stated above in additional fees. If requested by the co-signer to revoke the bond without probable cause, the co-signer will be responsible to reimburse the defendant his bond fees.

Date

Date

Date

Defendant

Co-Signer

Depositor

I, , agent of /Bankers Insurance Co. , certify that I have given a copy of all documents pertaining to this bail bond agreement to the defendant, the co-signer, the depositor or any of the above, at the time and date said bail bond agreement was executed.

Date Bail Bond Agent

OTHER CONDITIONS

COURT DATE: TIME: PLACE: NO DATE SET

INDEMNITOR INFORMATION In addition to the terms and conditions of any Indemnity Agreement or other collateral documents which you have executed, this is to notify you that:

1. The Indemnitor(s) will have the defendant(s) forthcoming before the court named in the bond, at the time therein fixed, and as may befurther ordered by the Court.

2. The Indemnitor(s) is responsible for any and all losses or costs of any kind whatsoever which the Surety may incur as a result of thisundertaking. There should not be any costs or losses provided the defendant(s) does not violate the conditions of the bond and appears on time at all required Court hearings.

3. Collateral will be returned to the person(s) named in the collateral receipt, or their legal assigns, within 10 days after the Surety hasreceived written notice of discharge of the bond(s) from the Court. It may take several weeks after the case(s) is disposed of before the court discharges the surety bonds.

PRINCIPAL ACKNOWLEDGMENT I have read and received a copy of this Disclosure Notice. I fully understand and agree that any breach of the conditions listed above may result in my surrender.

PRINCIPAL

INDEMNITOR ACKNOWLEDGMENT I have read and received a copy of this Disclosure Notice and understand and agree that should any breach of the conditions listed above occur, I may request/consent that the principal be surrendered by surety and agree to pay all costs incurred by Surety as a result of this undertaking. However, I do understand and agree that the Surety has no legal duty to comply with said request/consent made by indemnitor.

INDEMNITOR INDEMNITOR BIC4320690812

A completed copy of this notice must be kept in the Producer’s permanent file.

CO

MP

AN

Y

Bankers Insurance Company 11101 Roosevelt Blvd N St Petersburg, FL 33716 Phone: (800) 627-0000

PR

OD

UC

ER

RECEIPT #____________

D E S C R I P T I O N O F B A I L B O N D I S S U E DDEFENDANT LAST NAME

MIDDLE NAME

FIRST NAME

DATE OF BIRTH

BOND AMOUNT $

CASE NUMBER

POWER NUMBER

CHARGES AGAINST DEFENDANT

COURT NAME AND LOCATION

APPEARANCE DATE

TIME

PREMIUM RECEIPT .This is an important legal document. Keep it in a safe place

BOND PREMIUM $

FILING FEE / JAIL POSTING FEE $

TOTAL DUE for Premium/Posting/Filing Fees $

AMOUNT OF PREMIUM RECEIVED $

Cash Check Money Order Credit Card

BALANCE OF PREMIUM DUE: (payment terms must be in writing) $

DATE

RECEIVED FROM

Premium is held in trust for Bankers Insurance Company. If a refund is ordered by the Court after the bond is posted, premium will be returned in the amount and within the time specified by the court order. If the bail bond is not posted within twenty four hours, as required by law, all monies paid to the Producer must be returned within forty eight hours. PREMIUM RECEIVED BY PRODUCER: PRODUCER ACKNOWLEDGES RECEIPT OF THE PREMIUM AS SET FORTH ABOVE.

PRODUCER NAME (s. 10-2-705)

SIGNATURE

DATE SIGNED

CONSUMER ACKNOWLEDGEMENT FOR PREMIUM RECEIPTS: I have been given an original signed receipt for all premiums taken by the Producer in connection with this bail

transaction. CONSUMER NAME

SIGNATURE

DATE

A completed copy of this notice must be kept in the Producer’s permanent file.

CO

MP

AN

Y

Bankers Insurance Company 11101 Roosevelt Blvd N St Petersburg, FL 33716 Phone: (800) 627-0000

PR

OD

UC

ER

RECEIPT #__________

DD EE SS CC RR II PP TT II OO NN OO FF BB AA II LL BB OO NN DD II SS SS UU EE DD

DEFENDANT LAST NAME

MIDDLE NAME

FIRST NAME

DATE OF BIRTH

BOND AMOUNT $

CASE NUMBER

POWER NUMBER

CHARGES AGAINST DEFENDANT

COURT NAME AND LOCATION

APPEARANCE DATE

TIME

CCOOLLLLAATTEERRAALL RREECCEEIIPPTT

TThhiiss iiss aann iimmppoorrttaanntt lleeggaall ddooccuummeenntt.. KKeeeepp iitt iinn aa ssaaffee ppllaaccee.

COLLATERAL AMOUNT $

NAME, ADDRESS AND PHONE of person tendering the collateral.

DESCRIPTION OF COLLATERAL TENDERED

Cash Real Property Other (Attach list if necessary)

If applicable. Check here: No collateral, no cash taken

PERSONAL INDEMNITY ONLY

LIST OTHER RECEIPT NUMBERS APPLICABLE TO THIS TRANSACTION, IF ANY:

AA BBAAIILL BBOONNDD RREEMMAAIINNSS IINN FFUULLLL FFOORRCCEE AANNDD EEFFFFEECCTT UUNNTTIILL DDIISSCCHHAARRGGEEDD BBYY TTHHEE CCOOUURRTT

Real Property HAS / HAS NOT [check one] been pledged as collateral security. All collateral that is received by the Producer will be held without use, subject to the terms of the Bail Contract. Collateral is held by the Producer, in trust, for Bankers Insurance Company under the terms of the Bail Contract, which is incorporated herein by reference. Collateral will be returned after the Surety receives a Certificate of Discharge, or a true copy of the court order releasing and discharging the Bail Bond. It is Indemnitor’s responsibility to provide Surety with this documentation. Collateral will be return within fourteen (14) working days. Trust Deeds will be returned within thirty-five (35) working days. Documentation of the release and discharge of the Bail Bond must be presented to the Producer at the address that appears above. Collateral will only be returned to the same person who pledged the collateral. The Producer is not obligated to permit any exchange of collateral. If the bail bond is not posted within twenty-four hours of receipt of full payment, or a signed contract for payment, collateral must be returned and the lien released within forty-eight hours. Producer acknowledges RECEIPT of the collateral described above as of this date:

PRODUCER NAME (s. 10-2-705)

SIGNATURE DATE SIGNED

CCOONNSSUUMMEERR AACCKKNNOOWWLLEEDDGGEEMMEENNTT:: I HAVE BEEN GIVEN AN ORIGINAL SIGNED RECEIPT FOR ALL PREMIUM AND COLLATERAL TAKEN

BY THE PRODUCER IN CONNECTION WITH THIS BAIL TRANSACTION. CONSUMER NAME

SIGNATURE DATE

RECEIPT FOR RREETTUURRNN OF COLLATERAL (IMPORTANT: DO NOT SIGN THIS RECEIPT UNTIL THE COLLATERAL IS RETURNED TO YOU!)

I herewith acknowledge that the collateral identified above has been returned to me. CONSUMER NAME SIGNATURE DATE SIGNED