Small Contract Account Questionnaire - Iowa

Home Office: Scottsdale, Arizona Surety Administrative Office: 7 World Trade Center, 37th Floor 250 Greenwich Street New York, NY 10007-0033 1-888-800-0147 • Fax (480) 905-5454 SMALL CONTRACT ACCOUNT QUESTIONNAIRE—IOWA

Please complete this questionnaire in its entirety for single projects up to $350,000 and aggregate bond lines up to $500,000. Individual Credit Reports will be run on all business owners and spouses; therefore please be sure to include spousal information, if applicable, making sure that each and every individual signs the credit consent form. Please attach the following to your submission: • Any supporting information with regards to the company or the specific job request • Most recent Corporate Tax Return • Current Personal Financial Statement Once the forms have been completed and submitted to National Casualty Company, an underwriter will review your file. The underwriter may require additional information in order to support the requested bond. Corporate, Cross-Corporate, Personal and Spousal indemnity will be required on all submissions made to National Casualty Company. COMPANY INFORMATION Company Name: Federal Tax ID No.:

Address: Date Company Started:

City: State: Zip: Corporate Cash Balance:

Phone: Average Cash Balance:

Previous Surety Company: Bank Line of Credit Amount:

Reason for Leaving Prior Surety: Bank Line Outstanding:

Type of Work Performed:

Largest Job Completed To Date: 1. Do owner(s) have interests in other construction businesses?...... Yes No 2. Have you ever failed to complete a project?...... Yes No 3. Are you in litigation for any current or previous work?...... Yes No 4. Do you currently have any unfinished bonded contracts?...... Yes No 5. Has the contractor ever filed for corporate bankruptcy?...... Yes No 6. Has the contractor been in business for less than twelve (12) months?...... Yes No For questions 1.-6. above, please provide details for any “Yes” answers.

COMPANY OWNERSHIP INFORMATION

Ownership: % Title: Ownership: % Title: Name: Name: Owner SSN: Owner SSN: Home Address: Home Address: City: State: Zip: City: State: Zip: Owner’s Current Cash Balance $ Owner’s Current Cash Balance $ Has the Owner ever filed for personal bankruptcy?...... Yes No Has the Owner ever filed for personal bankruptcy?...... Yes No

Spouse Name: Spouse Name: Spouse SSN: Spouse SSN: Has the Spouse ever filed for personal bankruptcy?...... Yes No Has the Spouse ever filed for personal bankruptcy?...... Yes No

Ownership: % Title: Ownership: % Title: Name: Name: Owner SSN: Owner SSN: Home Address: Home Address:

SN-T-QUES-2-IA (12-13) Page 1 of 4 City: State: Zip: City: State: Zip: Owner’s Current Cash Balance $ Owner’s Current Cash Balance $ Has the Owner ever filed for personal bankruptcy?...... Yes No Has the Owner ever filed for personal bankruptcy?...... Yes No

Spouse Name: Spouse Name: Spouse SSN: Spouse SSN: Has the Spouse ever filed for personal bankruptcy?...... Yes No Has the Spouse ever filed for personal bankruptcy?...... Yes No

SN-T-QUES-2-IA (12-13) Page 2 of 4 PROJECT SPECIFIC INFORMATION Name & Address of Obligee: Project Name & Location:

If this is a final bond, what is the contract price? What is the bond amount, if different from the contract price?

If this is a bid, what is the estimated Bid Amount? What is the bid Percentage Requirement?

Bid Results (Name & Amount): 1st 2nd

Is the Project within one hundred fifty (150) miles of the Company’s office?...... Yes No What is the estimated number of days for completion? What are the per day Liquidated Damages? How long is the Maintenance period? How much of the work will be subcontracted out?...... % List any Subcontractors and their portion of work: Are there obligee specific bond forms required?...... Yes No (If “Yes,” please provide a copy for review) FRAUD PREVENTION—WARNING NOTICE TO APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM 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 PENALTIES.

Signed and sealed this day of , .

(Principal Signature) (Seal)

PRODUCED BY (Insurance Agent or Broker): Producer Name: Firm Name: Taxpayer ID or Social Security No.: Producer’s License No.: Agency: Address (No., Street, City, State and Zip):

SN-T-QUES-2-IA (12-13) Page 3 of 4 NOTICE OF INTENT TO REVIEW CONSUMER CREDIT INFORMATION You have represented that you have an interest in (Company Name) obtaining one or more bonds from National Casualty Company (“NCC”). NCC requires a review of your credit history before it makes a decision on whether to issue such a bond. In order to obtain such credit information, NCC is requesting your consent to do so. You will be notified if NCC declines to issue such bond if the reason for the declination is based completely or in part on the information contained in such report. Included with such notice will be the source of the report including addresses, phone numbers and instructions on how you can get a copy of your report so you can check it for accuracy. CONSENT TO OBTAIN CONSUMER CREDIT REPORT I, the undersigned, hereby consent to NCC obtaining a Consumer Report as defined under the Fair Credit Reporting Act which report will include information by a consumer reporting agency bearing on my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. I agree that a photocopy or facsimile of this agreement shall constitute a written instruction which NCC may present to a Consumer Credit Reporting Agency as proof of NCC’s authority to obtain such credit information. Signature of Person Granting Consent: Signature of Person Granting Consent:

(Printed Name of Person Granting Consent) (Printed Name of Person Granting Consent) Date: Date: Social Security Number: Social Security Number:

Signature of Person Granting Consent: Signature of Person Granting Consent:

SN-T-QUES-2-IA (12-13) Page 4 of 4