Insurer Quarterly Reporting Form

Surety Insurer Bail Bond Reporting Form

Please report required bond information by the 15th day after each calendar year quarter end.

1st Quarter - Aggregate Bond Liabilities as of March 31; report due to the OIC by April 15.

2nd Quarter - Aggregate Bond Liabilities as of June 30; report due to the OIC by July 15.

3rd Quarter - Aggregate Bond Liabilities as of September 30; report due to the OIC by October 15.

4th Quarter - Aggregate Bond Liabilities as of December 31; report due to the OIC by January 15.

Surety Insurer Bail Bond Quarterly Reporting Form

Insurer Name

NAIC Company Code

Insurer Contact First Name

Insurer Contact Last Name

Insurer Contact E-Mail

Insurer Contact Phone Number

Quarter Report for

Aggregate Number of Outstanding Bonds

Aggregate Bond Liability for all Outstanding Bonds

Attestation

I state that I have fully read and understand this monthly bail bond statement and that the answers supplied therein are true and correct to the best of my knowledge and belief and I further state that I recognize the applicable insurance laws of the State of West Virginia and the rules and regulations of the West Virginia Insurance Commissioner governing this quarterly statement - Title 114-CSR103.