19 MAC Pt. 1, R. 36.13
Exhibit A- Surety Bond for Public Adjuster Filed with the Mississippi
Cite as 19 Miss. Admin. Code Pt. 1, R. 36.13
Exhibit A- Surety Bond for Public Adjuster Filed with the Mississippi
Insurance Department
SURETY BOND FOR PUBLIC ADJUSTER FILED WITH
THE MISSISSIPPI INSURANCE DEPARTMENT
STATE OF ____________________
COUNTY OF ____________________
This form shall not be altered in any way.
Part 1: Bond, Surety and Principal.
Bond #:
Original Bond Date of
Issuance:
If a Continuation Bond, Effective
Date:
Name of the Surety Company:
NAIC # of Surety
Company:
MID License Number of Surety
Company:
Name of Principal (Public
Adjuster)
MID License Number of
Public Adjuster:
Amount of Bond:
$50,000.00
Part 2: Type and Bond Amount.
The type and amount of the bond for one year commencing on the original date of
issuance or continuation stated hereinabove at Part 1 is as follows:
Public Adjuster, Bond Equal to Fifty Thousand current U.S. Dollars ($50,000.00)
Part 3: KNOW ALL MEN BY THESE PRESENTS THAT, the Principal and Surety, who, after
being duly sworn, deposed and said:
THAT they are firmly bound unto the Commissioner of Insurance , State of Mississippi,
or his successor in office, under the surety bond, delivered in lieu of errors and omissions
liability insurance coverage, conditioned only for and dedicated exclusively to the prompt
payment of all claims arising and accruing to any persons who sustained damages as a result of
the Principals erroneous acts, failure to act, conviction of fraud, or conviction of unfair practices
in his capacity as a public adjuster for which the Principal and Surety bind themselves, their
heirs, administrators, executors, successors and assigns, jointly and severally, by this agreement;
THAT the Commissioner of Insurance shall be authorized to recover on behalf of any
person in the State of Mississippi who sustained damages described herein;
THAT the condition of this obligation is such that if the above named Principal shall
well and faithfully discharge and perform the duties incumbent on him under the provisions of
all applicable laws, including but not limited to Title 83 of the Mississippi Code and Mississippi
Insurance Department Regulation 2007-4, then in such case the above obligation is to become
null and void, else to remain in full force, effect and virtue;
THAT the provisions of all applicable laws, including but not limited to Title 83 of the
Mississippi Code and Mississippi Insurance Department Regulation 2007-4, for principals and
sureties are applicable;
THAT this surety bond shall not be terminated unless at least thirty days’ prior written
notice will have been filed with the Commissioner of Insurance, State of Mississippi, and given
to the principal;
THAT this obligation may be continued for any subsequent year by a continuation
certificate duly signed and sealed by the Principal and Surety, subject to the terms and conditions
of the original bond, and filed with the Commissioner of Insurance, State of Mississippi;
IN WITNESS THEREOF, Principal and Surety have executed this bond on the dates
stated hereinbelow.
Part 4. Signatures and Notary. Complete all information.
BY:
_____________________________________________________________________________
Principal
Date
Surety’s Authorized Representative Date
___________________
_______________________________________________
Print Name
Print Name/Title of Surety’s Authorized Representative
_________________________________
____________________________
Physical Address of Principal
Physical Address of Surety
Subscribed and sworn to before me this the _______ day of _______, 20__.
{Seal of Notary Public}
_________________________________
Notary Public
If a power of attorney is used, a copy of the power of attorney or the authorized agent of the
surety company must accompany the bond.