Dear Insurance Agent or Broker,

Thank you for choosing to use CBIC's Direct Bill Program. At any time in the process of filling out and submitting this form, should you have any questions, please call 1 (800) 765 2242, and ask for Kristi Brotherson, Leanna Widgren or Sarah Townsend in CBIC's Compliance Department.

Kristi, Leanna, Sarah

Your Name and Title
Your email address
Your Agency's Name
Agency CBIC Code No.
Agency Address
Phone Number
Fax Number

By submitting this form, I agree:

1 - To participate in Contractors Bonding and Insurance Company's (CBIC) Direct Bill Program.

2 - I understand that by choosing to participate in CBIC's Direct Bill Program, all bonds and policies that qualify will be direct billed, and will not appear on my account current statement. The following bonds and insurance policies qualify for CBIC Direct Bill:

A - Insurance Policies - Single pay or multi-pay.

B - Contrac Pac Plus, including both the bond and insurance policy, and single pay or multi-pay.

C - Bonds that may be cancelled - Single pay only.

3 - I understand that non-cancellable bonds, including all contract bonds, do not qualify for Direct Bill.

4 - I understand that I am solely responsible for collecting all down payments on new business that are billed through CBIC's Direct Bill Program.

5 - I acknowledge receipt of CBIC's Direct Bill Handbook, and, by submitting this form, I agree to the terms and conditions contained in the Handbook.

Agency person to contact regarding billings.

Thank you for doing business with CBIC.
If you have any questions, please call
1 (800) 765 2242.