VGMI Bid Bonds Application

Bid Bond Interest Form

By completing the form below, you are providing VGM Insurance with some basic information that will assist with streamlining your future Bid Bonds application. Completion of this form will also add you to an email distribution list to keep you updated with the latest information about Bid Bonds.

Legal Business Name*

Ownership

Has your ownership changed since your existing Surety Bond has been issued?*

Yes

If yes, please explain

Any ownership changes anticipated during the next 12 months?*

Yes

If yes, please explain:

Bidding Information

How many CBAs do you intend to bid on?*

Are all the CBAs you intend to bid on in your current service area? *

Yes

If no, how many CBAs are NOT in your current service area?

Are you bidding on only the products you currently service? *

Yes

If no, please explain.

Total Revenue

Total Annual Revenue ($)*

Percentage of Medicare*

Percentage of Medicaid*

Percentage of Other Revenue Mix*

Total above must equal 100%

Years in business?*

Years billing Medicare?*

First Name*	Last Name*


Email Address*

*Please note: This is not an official application form. The information supplied in this form will be used to assist with streamlining your official Bid Bonds application once the program begins. Completion of this form will also add you to a Bid Bonds email distribution list to keep you updated with the latest Bid Bonds information.