State of California Department of Insurance
Bond of Insurance Broker
LIC 417-5 (Rev 06/07)
Producer Licensing Bureau
P.O. Box 1139
Sacramento, CA 95814-1139
(916) 322-3555 or (800) 967-9331
www.insurance.ca.gov
TO THE PEOPLE OF THE STATE OF CALIFORNIA
(Insurance Code Sections 1662-1665)
BOND No. PREMIUM
WE, , as Principal, an applicant for or holder of a California
broker's license, and , an admitted surety insurer as Surety hereon,
bind ourselves in the penal sum of TEN THOUSAND DOLLARS ($10,000) to the people of the State of California, which
sum shall be the limit of total aggregate liability hereunder.
The condition of this obligation is that if the Principal is granted, or during the term hereof holds, an insurance
broker's license issued by the Insurance Commissioner of the State of California, he shall account to any person
requesting him to obtain insurance, for moneys or premiums collected by him, his solicitors or his employees, for
insurance other than life; if he shall so account as required by law, then this obligation shall be null and void;
otherwise to remain in full force and effect.
This bond shall take effect on ______________________, but not prior to the date of its execution. If no date is
hereinabove written, it shall take effect on the later of the two dates of execution set forth below.
This bond shall remain in force and effect until the Surety is released from further liability by the commissioner or
until the bond is canceled by the Surety. The Surety may cancel the bond and be released of further liability hereunder
by delivering 30 days' notice to the commissioner. Such cancellation shall not affect any liability incurred or accrued
prior to the termination of the 30-day period.
In witness whereof the Principal has subscribed his (its) true name on the date and at the place entered opposite his
(its) signature, and the Surety has subscribed its full and correct name and affixed its corporate seal on the date and at
the place in this State shown opposite its signature.
_______________________________________
Principal (print or type) Date
By
Place Where Executed
Surety
By
Name Date
Position or Title Place in California Where Executed
IT IS NECESSARY THAT A STATUTORY $24.00 REPLACEMENT BOND FEE BE SUBMITTED, UNLESS BOND IS FILED WITH
AN ORIGINAL APPLICATION.
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CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT
State of California
County of ____________________
On ______________ before me, ____________________________________________________
Insert name and title of officer here
personally appeared ______________________________________________________________
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to
the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized
capacity(ies), and that by his/her/their signatures(s) on the instrument the person(s), or the entity upon behalf
of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is
true and correct.
WITNESS my hand and official seal.
_________________________________________ (Notary Seal)
Signature of Notary Public
INFORMATION BELOW IS RECOMMENDED BUT NOT REQUIRED
TITLE/DESCRIPTION OF THE ATTACHED DOCUMENT
_____________________________________________________________________________________________
DOCUMENT DATE ______________________________________________ NUMBER OF PAGES _________________
_____________________________________________________________________________________________
Additional Information
CAPACITY CLAIMED BY SIGNER
Individual(s) Partner(s) Attorney-in-Fact Trustee(s)
Corporate Officer ________________________________ Other ____________________________________
2008 CA V13.01 .08
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