Join Palmetto Surety Corporation

Application to Become a Palmetto Surety Corporation Agent

Thank you for your interest in applying to become one of our agents! Please fill out this form and we will get in touch with you shortly.

Personal Information
Name*
First Last
Date of Birth*
Month
Day
Year
Social Security Number*
Driver's License Number*
Driver's License Issue Date*
Month
Day
Year
Driver's License Expiration Date*
Month
Day
Year
Residential Address*
Street Address Address Line 2 City State ZIP Code
Phone Number*
Email Address*
Enter Email Confirm Email
How long have you resided in the above city and state? (Years)
Please enter a number from 0 to 100.
Former Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
How long did you reside in the above residence? (Years)
Please enter a number from 0 to 100.
Have you ever been known by another name? (If no, leave blank)
Agent/Agency License Number
Home County
Bail Bond Information
Do you currently work in the Bail Bond Field?*
- Yes
- No
If yes, how long? (Years)
Please enter a number from 0 to 100.
Please list your current surety company/companies below
Company Name
Owner Name
Street Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Fax Number
Mobile Number
Duration of Ownership/Employment (Years)
Please enter a number from 0 to 100.
General Power of Attorney Information
Please list all of the counties for which you will need a General Power of Attorney Form
Company/Employer Information
Current Employer Name
Owner Name
Streeet Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Fax Number
Duration of Employment
Please enter a number from 0 to 100.
May this employer be contacted?
- Yes
- No
Employment History (Last 5 Years)
Name of Employer
Beginning Period of Employment
Month
Day
Year
Ending Period of Employment
Month
Day
Year
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Employer
Beginning Period of Employment
Month
Day
Year
Ending Period of Employment
Month
Day
Year
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Employer
Beginning Period of Employment
Month
Day
Year
Ending Period of Employment
Month
Day
Year
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
What type(s) of insurance license(s) do you currently hold?
Education Information
High School
City/State
Degree
Years Attended
Please enter a number from 0 to 25.
College
City/State
Degree
Years Attended
Please enter a number from 0 to 25.
Trade School
City/State
Degree
Years Attended
Please enter a number from 0 to 25.
Other Training
References
Name
First Last
Years Known
Please enter a number from 0 to 100.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name
First Last
Years Known
Please enter a number from 0 to 100.
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
To make the transition to Palmetto Surety Corporation as simple as possible, the following information is needed.
Face Value Volume Written Annually
Face Value Volume You Anticipate to Write with Palmetto Surety Corporation
Total Number of Estreatments
Number of Bonds Written Annually
Do you currently have a Build Up Fund with another Surety, Company or General Agency?
- Yes
- No
If yes, how much is in the account?
Please list any other assets that may be used as collateral, including cash, property and other holding accounts.
Financial Statement
Assets
Cash
Stocks/Bonds
IRA
Receivables
Home
Other Real Estate
Other Assets
Total Assets
Liabilities
Home Mortgage
Other Mortgages
Payables
Credit Cards
Taxes
Contingent Guaranty
Other Debt
Total Liabilities
Signature and Confirmation*

I hereby affirm, under penalty of perjury, that the foregoing declarations made and answers given are the truth without reservation. I authorize you to verify the information on this application and to receive and exchange information about me, including requesting reports from consumer reporting agencies, criminal reports, driving records and any other relevant source. I authorize Palmetto Surety Corporation to submit any information from this application to the South Carolina Department of Insurance or any business partner of the NIPR for licensing or information change purposes. If my application is approved, I authorize you to contact these sources for information at any time, to use information about me, including information from this application and from consumer reports.
Date*
Month
Day
Year

Join Palmetto Surety Corporation

Application to Become a Palmetto Surety Corporation Agent

Personal Information

Bail Bond Information

General Power of Attorney Information

Company/Employer Information

Employment History (Last 5 Years)

Education Information

References

To make the transition to Palmetto Surety Corporation as simple as possible, the following information is needed.

Financial Statement

Assets

Liabilities

we Can assist you 24/7
Click to Call 1 (866) 372-0827

Site Navigation

Corporate Offices

Navigation

Surety Bonds

Bail Bonds

Contact the Webmaster

Site Design and Marketing By MassImpact

Ⓒ 2022 Palmetto Surety Corporation - All Rights Are Reserved

Join Palmetto Surety Corporation

Application to Become a Palmetto Surety Corporation Agent

Personal Information

Bail Bond Information

General Power of Attorney Information

Company/Employer Information

Employment History (Last 5 Years)

Education Information

References

To make the transition to Palmetto Surety Corporation as simple as possible, the following information is needed.

Financial Statement

Assets

Liabilities

we Can assist you 24/7 Click to Call 1 (866) 372-0827

Site Navigation

Corporate Offices

Navigation

Surety Bonds

Bail Bonds

Contact the Webmaster

Site Design and Marketing By MassImpact​

Ⓒ 2022 Palmetto Surety Corporation - All Rights Are Reserved

we Can assist you 24/7
Click to Call 1 (866) 372-0827

Site Design and Marketing By MassImpact