CCO Bonds and Insurance Agency

CHB Company Name *

CCO Account Number (6 Digit)

Main Contact Name *

Phone Number *

Email Address *

Bond Amount ($50,000 minimum required) *

USD

Effective Date *

Importer Name *

Importer # *

Business Type *CorporationPartnershipProprietorshipIndividual

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Describe Merchandise *

Country(s) Shipping From *

Last Calendar Year

Merchandise Value *

USD

Estimated Duties *

USD

Current Year

Merchandise Value *

USD

Estimated Duties *

USD

Any Merchandise Subject to Antidumping and/or Countervailing Duties? *YesNo

Has a surety paid any claims for an existing/previous bond? *YesNo

Company Officer Name *

Company Officer Title *

I certify that the factual information contained in this application is true and accurate and any information provided which is based upon estimates is based upon the best information available on the date of this application. I also hereby acknowledge that there will be no Antidumping/Countervailing Duty entries made against the bond without prior approval of the Surety.