New Jersey, NJ Electrical Contractor Business Permit Bond Application

James C. Franchino Agency, Inc.
PO Box 36, Florham Park, NJ 07932-0036
Phone: 973-377-6100

Note: Please PRINT this blank application, fill it out completely, and MAIL it to the agency WITH payment. Please do not fax us this form. Application must be accompanied by a check (check does NOT have to be certified) or money order for $50.00 (Fifty Dollars) made out to: James C. Franchino Agency Inc.

The bond will be issued April 1, 2006, or the date received after April 1st; It will expire March 31, 2009

BUSINESS NAME to appear on the bond (same as your business permit):

______________________________________________________________________________________

(Please look at your present business permit if renewing.)

Your name: ____________________________________________________________________________

Street: ________________________________________________________________________________

City: ______________________ County: ____________________ State: ___________ Zip: ____________

Electrical license number, (if renewal): __________________________

Home phone # (           ) ____________________ Business phone # (           ) _______________________

Cell phone # (               ) _______________________________________

Fax number # (           ) ____________________, This a dedicated fax _____; Call first _____

Email address: __________________________________________________________

Below find general fraud statement that needs to be signed. This statement is required by the NJ Dept. of Insurance for all new policies. General Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or another 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 and subjects the person to criminal and civil penalties.

Signature: _________________________________________ Date: ___________________

Expiration date and name of your current insurance company currently providing electrical contractor general liability coverage ______________________________________________________________________

Thank you very much. Your bond will be issued promptly!