APPENDIX B
REQUEST FOR LISTING BY NEW JERSEY DEPARTMENT OF INSURANCE AS ACCEPTABLE SURETY FOR PROVISION OF BONDS ON PUBLIC CONTRACTS PURSUANT TO P.L. 1995, C. 384
COMPANY NAME ________________________________________________
ADDRESS _____________________________________________________
_____________________________________________________________
TELEPHONE NO. _______________________________________________
COMPANY NAIC NUMBER
_____________________________________________________________ GROUP NAME
_____________________________________________________________ GROUP NAIC NUMBER
_____________________________________________________________
I, _______________________, hereby file this certification on (Name and Title) behalf of __________________________ in connection with this (Name of Surety) company's application to be listed by New Jersey Department of Banking and Insurance for purposes of providing payment and performance bonds pursuant to P.L. 1995, c. 384. I further certify that I am authorized to execute this certified statement on behalf of _______________________________________ (Name of Surety)
PART I
1. The above-referenced surety is listed in the most recent United States Treasury Circular 570 issued July 1 of each year. Yes ___ No ___
If yes, go to Part III; if no, complete Part II.
PART II
1. The above-referenced surety is currently listed to transact business in the following jurisdictions for the following lines:
Jurisdiction Line
____________________________ ____________________________
____________________________ ____________________________
____________________________ ____________________________
(Attach additional sheets if necessary)
2. The above-referenced surety's capital and surplus or net cash assets, as of December 31 immediately preceding is $_______, as reported in the statutory annual statement for that year. This amount satisfies the statutorily prescribed minimum capital and surplus or net cash asset requirements for all lines of insurance that the surety is authorized to write pursuant to the certificate of authority issued by its domiciliary jurisdiction and all states in which it is licensed to transact business. Yes __ No __
3. The above-referenced surety has been found to be in a hazardous financial condition by the Commissioner, its domiciliary jurisdiction, or any jurisdiction in which it is licensed, as determined pursuant to N.J.A.C. 11:2-27 or such other equivalent requirements in other jurisdictions in which the surety is licensed. Yes __ No __
If yes, indicate jurisdiction(s) and details regarding such finding below.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
4. The above-referenced surety's premium to surplus ratio as of December 31 immediately preceding is _______ and loss and loss adjustment expense reserve liability to surplus ratio for that period is __________, as reported in the statutory annual statement for that period.
5. The above-referenced surety has failed four or more IRIS tests. Yes __ No __
If yes, provide an explanation that demonstrates that such results are not indicative that the surety is in a hazardous financial condition.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
PART III
Dated and signed this ______ day of _____________. I hereby certify that the foregoing statements are true and correct to the best of my knowledge and belief. I further certify that I am aware that the New Jersey Department of Banking and Insurance will rely on this certification in connection with its determination whether the surety satisfies the requirements set forth in N.J.A.C. 11:1-41 for purposes of providing payment and performance bonds pursuant to P.L. 1995, c. 384.
I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment.
__________________________ (Signature of Affiant)
Amended by R. 2001 d. 99, effective March 19, 2001. See: 32 N.J.R. 4194(a), 33 N.J.R. 1004(a).