S-1 Form S-1 Surety Company Annual Report

U.S. Department of Labor
Office of Labor-Management
Standards
Washington, DC 20210

Form Approved
Office of Management
and Budget
No. 1245-0003
Expires10-31-2013
00-30-206
Expires

FORM S-1
SURETY COMPANY ANNUAL REPORT
READ THE INSTRUCTIONS CAREFULLY BEFORE PREPARING THIS REPORT.

For Official Use Only

This form is for use by surety companies in filing reports on bond experience with respect to bonds required by the
Labor-Management Reporting and Disclosure Act of 1959, as amended (LMRDA), and under the Employee Retirement Income
Security Act if 1974 (ERISA). This report is mandatory under P.L. 86-257, as amended. Failure to comply may result in criminal
prosecution, fines, or civil penalties as provided by 29 U.S.C. 439 or 440.

E
Part I - Identification
1. File Number S -

2. For Year Ending:

3. Name of surety company
4. Address of principal office
P.O. Box, Bldg., Room No., if any
Number and Street
City
ZIP Code + 4

State

Part II - Premium Data
LMRDA (Class Codes 691-692-695)
Honesty
Faithful Discharge
[1]
[2]

ERISA (Class Codes 697-872)
Honesty
Faithful Discharge
[3]
[4]

5. Direct Premiums Written
6. Direct Premiums Earned
7. Expenses Incurred - Other than Loss Adjustment
8. Percent of Direct Premiums Earned Allocated to Expenses
Incurred [Item 7 divided by Item 6]

0%

0%

0%

0%

0%

0%

0%

0%

Part III - Loss Data
9. Direct Losses Paid
10. Direct Losses Incurred
11. Direct Loss Adjustment Expenses Incurred
12. Direct Salvage Recovered
13. Net Losses (Item 10 + Item 11 - Item 12)
14. Percent of Direct Premiums Earned Allocated to Net Losses
[Item 13 divided by Item 6]
Signatures
Each of the undersigned, duly authorized officers of the above surety company, declares, under penalty of perjury and other applicable penalties of law,
that all of the information submitted in this report (including the information contained in any accompanying documents) has been examined by the signatory
and is, to the best of the undersigned's knowledge and belief, true, correct, and complete. (See the section on penalties in the instructions.)

17. Signed

President

President
(If other title, see
instructions)

18. Signed

Treasurer

On

On
Date
Form S-1 (2003)

Treasurer
(If other title, see
instructions)

Telephone Number

Date

Print Report

Telephone Number

Page 1 of 2

File Number

Name of Surety Company

Ending Date of the Period Covered
S-

Part IV - Itemization of Losses Reported During Year
15. Report Information for Each Loss for Which a Notice Was Received During the Report Year
a. Date notice of loss received

Add More Loss Information

b. Name and Address of Insured Sustaining Loss
Organization Name
P.O. Box, Bldg., Room No., if any
Number and Street
City
ZIP Code + 4

State
c. Bond class code

d. Amount of bond coverage available

e. Gross loss to insured (if known)

f. Amount paid to insured in report year

g. Amount of salvage recovered in report year

16. Additional Information
Item Number:

Form S-1 (2003)

Description:

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