ARCY KHAN Agent Indemnity Application!

Ali Baba Bail Bonds LLC Indemnity Contract & Promissory Note
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Verified signer

Yes NO
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Please have your Identification & Paystub ready.

Identification, e.g., Drivers license, Passport, Greencard

Note: This application will require the submission of your identification & paystub. Please have a scanned image, screenshot, or photocopy of your paystub & ID ready.

Click Next when you are ready to begin.

Confirm Cell Phone Number
We need to confirm your Cell Number. Please Type in your cell number and press OK to obtain a code; enter your code, then click Confirm again. *
Once your cell phone number is successfully confirmed, click the "NEXT" button on the page's bottom right to continue.

Your Information
What is your Relationship to the Defendant?
Your Name

First Name Middle Name Last Name
Your Date of Birth

Month Day Year
Your Social Security Number
This information is necessary for identity verification & background check
Your Gender

Male Female

Place of Birth
Were you born in the U.S.A.? *

Yes I was born in the U.S.A. No, I was not born in the U.S.A

U.S.A. Citizen Status
What is your U.S.A. citizen status? *

Permanent Resident "Green Card" Naturalized Citizen

Immigration Status
What is your country of origin?
In what court did your naturalization oath ceremony take place at?
In what year did you become a green-card holder?

Month Day Year
in what year did you become a naturalized citizen?

Month Day Year

Employment
Are You Currently Employed? *

Yes, I am Currently Employed No, I am not Currently Employed

Vehicle Information
Do You own/lease a Vehicle? *

Yes, I own/lease a Vehicle No, I do not own/lease a Vehicle

Home Owner
Are you a home owner? *

Yes, I own a home No, I do not own a home

Lease Information
Is the lease at your rented address in Your Name? *

Yes, I rent and the lease is in my name No, the lease is not in my name

Lease Holder
Who is the lease holder at your residence?

First Name Last Name
What is their relationship to you?
Phone Number

Your Residence
Your Home Address. Click to verify *
How long have you lived at your current residence?

0 - 6 months 6 months - 1 year 1 - 2 years 2 or more years

Your Contact Information
Your Verified Mobile Number
Your Mobile Number
Social Media Name
i.e. facebook / instagram / snapchat
Your Email
example@example.com

Contact Reference

Neighbor, Friend, Family-member , Co-worker or Associate not signing for the bond
1st Reference

First Name Last Name
1st Reference Phone Number
1st Reference Relationship to You?
2nd Reference

First Name Last Name
2nd Reference Phone Number
2nd Reference Relationship to You?

Your Vehicle Information
What State your Vehicle is Registered in?

Street Address

Street Address Line 2

State
Plate / Tag # of your Vehicle
Color of your Vehicle
Make & Model of your Vehicle
Year of your Vehicle

Employment Information
Have you been employed with your current employment for over 1 year

Yes No
How many months have you been employed with your current employer
How many years have you been employed with your current employer?
What is the name of the company you work for?
What is your occupation?
What is your average weekly income?

Employment Address & Contact
Work Address

Street Address

Street Address Line 2

City State

Zip Code
Your Employer's Phone Number

Defendant's Bond Information
Where is the Defendant Incarcerated?
Provide the location where the defendant is detained, i.e., the name of the police department, jail or courthouse?
Is the Defendant held on more than one bond *

Yes, the defendant is held on multiple bonds No, the defendant only has one bond
How Many Bonds is the defendant held on
Select the number of bonds the defendant is being held on
Bond Amount *
Bond PremiumAmount
CT Bond Premium Rate
2nd Bond Amount
2nd Premium Amount
CT Bond Premium Rate
3rd Bond Amount
3rd Premium Amount
CT Bond Premium Rate
4th Bond Amount
4th Premium Amount
CT Bond Premium Rate
5th Bond Amount
5th Premium Amount
CT Bond Premium Rate
6th Bond Amount
6th Premium Amount
CT Bond Premium Rate
7th Bond Amount
7th Premium Amount
CT Bond Premium Rate
8th Bond Amount
8th Premium Amount
CT Bond Premium Rate
9th Bond Amount
9th Premium Amount
CT Bond Premium Rate
10th Bond Amount
10thPremiumAmount
CT Bond Premium Rate
hiden Total Bond Amount *
CT Bond Amount
hiden Total Premium
CT Bond Premium Rate
Total Bond Amount
Total Premium

Defendant's Information
What is the Defendants citizen status?

The defendant was born in the USA The defendant is a USA green card holder The defendant is a Naturalized citizen None of the above
Is the Defendant Employed?

Yes, the defendant is employed No, the defendant is not employed
Does the Defendant have prior arrest?

Yes, the defendant has a prior arrest No, this is the defendant's first arrest

Defendant's Personal Information
Defendant's Name

First Name Middle Name Last Name
Defendant's Date of Birth

Month Day Year

Defendant's Residence
Defendant's Home Address

Street Address

Street Address Line 2

City State

Zip Code
How long has the Defendant lived at the listed Address?

0 - 6 months 6 months - 1 year 1 - 2 years 2 or more years

Defendant's Contact Information
Defendant's Mobile Number
Social Media Name
i.e. facebook / snapchat / instagram
Defendant's Email
example@example.com

Documents Needed

Have your identification & paystub ready
Take a Photo/Selfie of Yourself *

Tap here
Tip: You can use your cell front or back camera Cancel of
Take a Photo of your Identification *

Tap here
You can use your Drivers license or passport. Tip: You can use your camera or upload from your browser. Cancel of
Take a Photo of your Paystub

Tap here
Tip: You can use your camera or upload from your browser. Cancel of

Documents Needed

Have your identification ready.
Take a Photo of your Green Card

Tap Here
Tip: You can use your camera or upload from your browser. Cancel of
Take a Photo of your Passport

Tap Here
Tip: You can use your camera or upload from your browser. Cancel of

Bond & Premium
Total Bond Amount
Total Premium
Will the Premium of the Bond will be paid in full today? *

Yes, the premium will be paid in full today No, Need to apply for a Payment Plan
Are You making an electronic payment with Credit Card, PayPal, Cash App or Venmo? *

Yes, I want to make an electronic payment No, The bond will be paid with cash
How would you like to make a payment? You Can select more then one option. There is a 3% fee for any Credit Card transaction. You may see this fee on your next invoice *

Credit Card/PayPal Cash App Venmo

Payment Options Record
Front of Credit Card

Take Photo
Front CC Image Cancel of
Back of Credit Card

Take Photo
Back CC Image Cancel of
Click on the link to make the payment Via Cash app. Save your web receipt to your device. Then, return to the form to upload your web receipt in the payment form

Click here to cash.app Arcy Khan
Upload Cash App Web receipt

Upload
To keep a record with your file Cancel of
Click on the link to make the payment Via Venmo. Save your web receipt to your device. Then, return to the form to upload your web receipt in the payment form

Click Here to Venmo Arcy-Khan
Upload Venmo Web receipt

Upload
To keep a record with your file Cancel of

Payment Plan Options
Installment Payment Plan (select one)

Weekly (60 payments or less) Bi-weekly (30 payments or less) Monthly (15 payments or less)
Weekly Payments Entering (8 Payments or less)
Select the weeks needed to pay off your balance as discussed with the Bail Agent
Bi-Weekly Payments Entering (30 payments or less)
Select the Bi-Weekly payments needed to pay off your balance as discussed with the Bail Agent
Monthly Payments Entering (15 Payments or less)
Select the months needed to pay off your balance as discussed with the Bail Agent
Initial Payment due Date

Month Day Year

Premium Downpayment
Total Bond Amount
Total Premium
Premium Downpayment
Fill in the agreed-upon down payment discussed with the Bail Agent here.
min Premium Downpayment
Unpaid Balance
The total Unpaid Balance will be adjusted if there are multiple bonds. (Must be fully paid within 15 months by CT Public Act 11-45)

Incorrect Down Payment
The down-payment was not approved. Enter the down-payment amount that you discussed with your Bail Agent!

Tap on the back button to make a correction on the premium down payment

Terms & Condition Contract
Indemnity Contract *

Payment Plan Agreement
Payment Plan Contract *

Signature

You are signing an agreement for all terms and conditions that you have agreed upon.
"Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning"
"any fact material thereto commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for" "each such violation.."
I, {yourName} the undersigned Indemnitor (“Indemnitor” or “you”), hereby represent and warrant that the following declarations made, and answers given are true, complete and correct and are made for the purpose of inducing Ali Baba Bail Bonds LLC. (“Surety”) to issue, or cause to be issued, bail bond(s) or undertaking(s) for you (singularly or collectively the “Bond”) for {defendantsName21}. Agree to the terms set forth on All Pages of this Agreement
Signature *

How Would You Rate our service

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1 is Worst, 5 is Best

Would you like to leave us a Review?

Yes No
How would you like to see us improve?
Who was your Bail Agent?
Today's Date

Month Day Year

Electronic Payment
Credit Card Payment Amount
Convenience Fee 3%
Total Charges
Credit Card Payment Amount

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USD Bond Premium
Form name

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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Ali Baba Bail Bonds LLC Indemnity Contract & Promissory Note

Confirm Cell Phone Number

Your Information

Place of Birth

U.S.A. Citizen Status

Immigration Status

Employment

Vehicle Information

Home Owner

Lease Information

Lease Holder

Your Residence

Your Contact Information

Contact Reference

Your Vehicle Information

Employment Information

Employment Address & Contact

Defendant's Bond Information

Defendant's Information

Defendant's Personal Information

Defendant's Residence

Defendant's Contact Information

Documents Needed

Documents Needed

Bond & Premium

Payment Options Record

Payment Plan Options

Premium Downpayment

Incorrect Down Payment

Terms & Condition Contract

Payment Plan Agreement

Signature

Electronic Payment