Oregon Fuel Bond Application — Business Insurance Brokers

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Sensitive information notice: This application requires personal information including Social Security Numbers and dates of birth, which surety companies use for credit underwriting to determine bond eligibility and premium. Your information is transmitted securely and used solely for bond underwriting purposes. Fields marked SENSITIVE contain this data.

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Business Information

Legal entity, tax ID, and contact details

Entity Name * DBA (if different) Tax ID / EIN # * Sensitive Primary Contact Phone # * Email Address * Physical Address Street Address * City * State * Select... Oregon WashingtonIdahoNevada ArkansasSouth Dakota PennsylvaniaTexasIndiana Other ZIP Code * Mailing Address (if different from physical) Mailing Street Address City State ZIP 📜 Bond DetailsTerm and coverage requirements Requested Bond Term * Select... 1 year 2 years 3 years Requested Bond Amount (if known) Select or unknown... $5,000$10,000$15,000 $20,000$25,000$50,000 $75,000$100,000 Amount determined by ODOT Unknown — broker to advise Type of Oregon Fuel License *

DBA (if different)

Tax ID / EIN # Sensitive

Primary Contact Phone #

Email Address

Physical Address

Street Address

City

State

ZIP Code

Mailing Address (if different from physical)

Mailing Street Address

City

State

ZIP

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Bond Details

Term and coverage requirements

Requested Bond Term

Requested Bond Amount (if known)

Type of Oregon Fuel License

Fuel Dealer Fuel Distributor Dealer & Distributor Other / Unknown

Requested Effective Date 👤 Owner Information All owners — surety companies require individual credit review for each Multiple owners: If this business has more than one owner, add each owner separately using the button below. Surety underwriters review all owners with an ownership stake. Add Another Owner Ready to Submit? A licensed broker will review your application and contact you within one business day with bond options and next steps. Loading... Submit Bond Application › ✓ Your Oregon Fuel Bond application has been received. A broker will contact you within one business day. Thank you! By submitting this form, you authorize Business Insurance Brokers and its licensed agents to use the provided personal information solely for the purpose of obtaining surety bond quotes on your behalf. Your Social Security Number and other sensitive data are transmitted securely and will not be shared beyond the underwriting process. You may contact us at [email protected] with any questions. Jump to Submit // ── PROGRESS ────────────────────────────────────────────────────────────────── function updateProgress(){ const els=document.querySelectorAll('[name]:not(.hp)'); let total=0,filled=0;const seen=new Set(); els.forEach(el=>{ if(!el.name) return; if(el.type==='radio'||el.type==='checkbox'){ if(seen.has(el.name)) return; seen.add(el.name);total++; if(document.querySelector(`[name="${el.name}"]:checked`)) filled++; } else {total++;if(el.value&&el.value.trim()) filled++;} }); const pct=total?Math.round((filled/total)*100):0; document.getElementById('progressFill').style.width=pct+'%'; document.getElementById('progressLabel').textContent=pct+'% complete'; } document.addEventListener('input',updateProgress); document.addEventListener('change',updateProgress); // ── OWNER REPEATER ──────────────────────────────────────────────────────────── let ownerCount=0; function toggleSpouse(n, el){ const panel=document.getElementById('spouse_panel_'+n); if(panel) panel.style.display=el.value==='Married'?'block':'none'; } function toggleRealEstate(n, el){ const detail=document.getElementById('re_detail_'+n); if(detail) detail.style.display=el.value==='Yes'?'block':'none'; } function addOwner(){ ownerCount++; const n=ownerCount; const div=document.createElement('div'); div.className='owner-card'; div.id='owner_'+n; div.innerHTML=` ${n} Owner ${n}${n===1?' (Primary)':''} ${n>1?`Remove`:''} Full Name * Ownership % * Date of Birth * Sensitive Social Security Number * Sensitive Marital Status *

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Owner Information

All owners — surety companies require individual credit review for each

Multiple owners: If this business has more than one owner, add each owner separately using the button below. Surety underwriters review all owners with an ownership stake.

Ready to Submit?

A licensed broker will review your application and contact you within one business day with bond options and next steps.

By submitting this form, you authorize Business Insurance Brokers and its licensed agents to use the provided personal information solely for the purpose of obtaining surety bond quotes on your behalf. Your Social Security Number and other sensitive data are transmitted securely and will not be shared beyond the underwriting process. You may contact us at CommercialInsuranceAgency@gmail.com with any questions.