New Jersey, NJ Master Plumbers 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 this form to us. 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.

  TERM OF THE BOND:  When received until June 30, 2009.
COST OF THIS BOND: $50. Fifty Dollars for the term.

The Board of Master Plumbers has instructed us to issue the bond in your individual name, (natural name), NOT a company or trade name.

Your Name ___________________________________________________________________________

Business name: (for reference only)________________________________________________________

Street: _______________________________________________________________________________

City: ______________________________ County : ____________________

State: _________________ Zip: ____________

Master plumber license number, (if renewal): __________________________

Home phone # (                  ) _________________________________

Business phone # (              ) ________________________________

Cell # (              ) __________________________________________

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: ___________________