Excise Bond Underwriters

15 Maiden Lane, Suite 800, New York, NY 10038
Telephone (212) 363-2950 Fax (212) 425-2539

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Application

Agents / Brokers: Complete, Print & Fax the signed Application with a copy of the first page of your client's most current personal tax returns, to (212) 425-2539. Mail the original to the above address.

All Others: Complete, print, sign and mail the original application with payment and the first page of the signer's most current personal tax returns to the above address.

Name of Applicant (s)

Street Address of Place of Business

Trade Name

City, State, Zip Code

E-mail Address

County

INDICATE BY MARKING AN "X" IN THE PROPER , THE DESCRIPTION
OF YOUR BUSINESS AS IT WILL APPEAR ON YOUR APPLICATION FOR A LICENSE.

MANUFACTURER		PENAL AMT OF BOND	PREMIUM
			1 YEAR	2 YEARS	3 YEARS
	Micro Brewer	$1,000.00	$50.00
	Brewer	15,000.00	180.00
	Distiller (Class A)	25,000.00	300.00	525.00	750.00
	Distiller (Class B)	25,000.00	300.00	525.00	750.00
	Distiller (Class B1)	5,000.00	90.00	157.50	225.00
	Distiller (Class C)	5,000.00	60.00	105.00	150.00
	Wineries	10,000.00	120.00	210.00	300.00
	Cider Producer and/or Sale	1,000.00	50.00
	Farm Winery	1,000.00	50.00	75.00	100.00

WHOLESALER		PENAL AMT OF BOND	PREMIUM
			1 YEAR	2 YEARS	3 YEARS
	Beer	$10,000.00	$120.00
	Wine	10,000.00	120.00	210.00	300.00
	Liquor	20,000.00	240.00	420.00	600.00

	VENDOR	1,000.00	50.00	75.00	100.00

OFF-PREMISE		PENAL AMT OF BOND	PREMIUM
			1 YEAR	2 YEARS	3 YEARS
	Beer (Grocery or Drug Store)	$1,000.00	$50.00	$75.00	$100.00
	Wine and Cider	1,000.00	50.00	75.00
	Liquor (Liquor Store)	1,000.00	50.00	75.00	100.00
	Beer / Wine Products	1,000.00	50.00	75.00	100.00

ON PREMISE		PENAL AMT OF BOND	PREMIUM
			1 YEAR	2 YEARS	3 YEARS
BEER
	Eating Place	$1,000.00	$50.00	$75.00	$100.00
	Ballpark or Racetrack	1,000.00	50.00	75.00	100.00
	Vessel	1,000.00	50.00	75.00	100.00
	Summer Only	1,000.00	50.00
	Winter Only	1,000.00	50.00

WINE, BEER, AND CIDER		PENAL AMT OF BOND	PREMIUM
			1 YEAR	2 YEARS	3 YEARS
	Club, Hotel or Restaurant	$1,000.00	$50.00	$75.00

LIQUOR, WINE, AND BEER		PENAL AMT OF BOND	PREMIUM
			1 YEAR	2 YEARS	3 YEARS
	Restaurant, Hotel, Club Tavern, Catering Establishment or Vessel	$1,000.00	$50.00	$75.00
	Restaurant Brewer	2,000.00	100.00	150.00	200.00
	Railroad Car	1,000.00	50.00	75.00
	Summer Only	1,000.00	50.00
	Winter Only	1,000.00	50.00

PERMITTEES		PENAL AMT OF BOND	PREMIUM
			1 YEAR	2 YEARS	3 YEARS
	Bottling	$5,000.00	$75.00	$131.25	$187.50
	Broker	1,000.00	50.00	75.00	100.00
	Warehouse	5,000.00	50.00	87.50	125.00
	Trucking (No. of Trucks Operating Under Permit)	1,000.00	*50.00	*75.00	*100.00
Add 60¢ for each truck in excess of three, max. $60.00 2 yr. premium $75.00 + $1.05 for each truck in excess of three, max. $105.00 *3 yr. premium $100.00 + $1.50 for each truck in excess of three, max. $150.00
	Fleet Trucking	1,000.00	60.00
	SOLICITOR	1,000.00	50.00	75.00	100.00
SOLICITOR PERMIT **(WRITE EMPLOYER'S NAME BELOW)

** FOR TRUCKING PERMIT BONDS ONLY

EMPLOYER'S NAME:
STREET ADDRESS:
CITY AND COUNTY OF:

PRODUCER INFORMATION
BROKER OR GENERAL AGENT:
STREET ADDRESS:
CITY, STATE, ZIP CODE:
AGENT/BROKER'S LICENSE #:
AGENT'S COMPANY:
TELEPHONE NUMBER:
E-MAIL ADDRESS:

Any person who knowingly and with intent to defraud any insurance company or other 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.

I, or we, personally, as well as an officer of the corporation, on behalf of the corporation or partnership, agree to pay the original premium and any subsequent or additional premium and agree to indemnify and keep indemnified the Company and save it harmless from and against any and all losses, demands, liabilities and expenses including attorney and counsel fees, which it shall at any time sustain or incur and will pay over, reimburse the Company, its successors and assigns, all sums and amounts of money which the Company or its representatives shall pay or cause to be paid, or become liable to pay under its obligations under said bond; or any charges or expense incurred in the investigation or in connection with any litigation by reason of the execution thereof; and will upon demand place the Company in funds with which to meet any such claim or expense, even though the Company or its representatives shall have paid, out such sum or any part thereof or not.

APPLICANT / PERSONAL GUARANTOR SIGNATURE REQUIRED:	X
PRINT NAME:
HOME ADDRESS:
CITY, STATE, ZIP CODE:
HOME PHONE:
SOCIAL SECURITY #:
Dated this day of A.D.

IF CORPORATION SIGN HERE ***

(Name of Corporation)


	Officer

***NOTICE - IF CORPORATION - THE APPLICATION MUST BE
SIGNED BY LICENSEE AS APPLICANT/PERSONAL GUARANTOR AND CORPORATION.
ALL APPLICATIONS ARE TO BE SIGNED AND RETURNED WITHIN TEN (10) DAYS.

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