BUF Account Set-Up | O'ShaughnaHill Surety & Insurance, Inc

Agency Number Office Only :

Agent Name (Account Name):

Bank Statement Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

* Please notify OSI immediately if statements are not received on a monthly basis.

Social Security Number:

Agency EIN Number:

Initial Deposit of $

(Make checks payable to the name on account.)

Included

Yes
No

Include the following with this completed BUF Set-up Form:

Legible (enlarged) copy of your Driver’s License (or other valid ID)
Completed and signed W-9 Form
Proof of Business Registration from SUNBIZ.ORG

I fully understand this BUF account is open in accordance with my Bail Bond Agreement between agent (General Agent, Producer, Sub-Producer, et al) and O’Shaughnahill Surety & Insurance Inc. This BUF account will be opened using either my Social Security number or Business Account using my EIN. Agent, as owner of the account will pay all taxes due and payable with respect to income with this account. O’Shaughnahill Surety & Insurance Inc. as the custodian and signer on the account is the sole authority to withdraw funds or close the account.

Signature

Date