State of Connecticut
 
Connecticut Insurance Department

Bail Bond Certification

Pursuant to CGS 38a-660 sec. 3(b), a surety bail bond agent is required to file this Certification under oath not later than the tenth day of each month.


MONTH:  
YEAR:  
1) Number of Surety Bonds Written:  
1A) Transfer Bonds:  
2) Total Face Amount of All Surety Bonds Written:  
3) Total Amount of Premium Collected on Surety Bonds Written:  
3A) Transfer Bonds:  
4) Number of Premium Finance Arrangements Entered Into:  
5) Total Amount Collected on Premium Finance Arrangements Entered Into:  

ATTESTATION:

BY ENTERING MY SIGNATURE BELOW I ATTEST AND CERTIFY UNDER OATH THAT I HAVE CHARGED THE CORRECT PREMIUM RATE FOR ALL SURETY BONDS, AND THAT I HAVE NOT CHARGED LESS THAN, OR MORE THAN, THE FILED PREMIUM RATE AS SET BY LAW. ADDITIONALLY, OTHER THAN THE PREMIUM RECEIVED FOR THE BOND, I HAVE NOT ACCEPTED ANYTHING OF VALUE FROM, NOR RETURNED PREMIUM MONEY TO, CONSUMERS AS AN INDUCEMENT FOR ISSUING A SURETY BAIL BOND.

I ALSO CERTIFY UNDER PENALTY OF PERJURY, THAT I AM THE PERSON NAMED HEREIN AND THAT ALL INFORMATION SUBMITTED ON THIS FORM IS TRUE AND COMPLETE. I ATTEST THAT I HAVE THE AUTHORITY AND CAPACITY TO EXECUTE THIS CERTIFICATION. I AM AWARE THAT SUBMITTING FALSE INFORMATION OR OMITTING PERTINENT OR MATERIAL INFORMATION IN CONNECTION WITH THIS FORM IS GROUNDS FOR ADMINISTRATIVE SANCTION INCLUDING FINES, SUSPENSION OR REVOCATION OF MY LICENSE BY THE DEPARTMENT.

NOTE: The filing of a false certification by a surety bail bond agent or failure to file the certification by the tenth of each month shall be grounds for administrative action in accordance with section 38a-774 of the general statutes. Should the tenth of the month fall on a legal holiday or weekend, the form will be due the next business day following.

PRINT NAME:  
E-MAIL ADDRESS:  
(This should be your valid e-mail address to receive the confirmation of your submission)
Confirm E-MAIL ADDRESS:  
CT BAIL BOND LICENSE NUMBER:  
SIGNATURE ID:  
(Use the last four digits of your SSN number for Individual or last four digits of the Tax-ID for Business Entity)






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