Notary Public Application
Alexi Giannoulias Illinois Secretary of State
Return completed form to: Secretary of State Index Department, 111 E. Monroe, Springfield, IL 62756.

Last Name: First Name: Middle Name or Initial:

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Business Address:
Street: City: State: ZIP:

Name of Employer: Driver’s License or State Identification
Card Number (attach a photocopy):
Business Phone: Date of Birth: Applying for: n New Commission n Renewal of Commission
Current Expiration Date: _________ Commission Number: ____________
Email Address: Home Phone: County of Residence:

Current Home Address (Driver’s License address must match):
Street: City: State: ZIP:

Has your name, address or county changed since your last commission n Yes n No
If, yes, give previous name, address and/or county: _______________________________________________________________________________________

NOTARIAL OATH State of Illinois, County of____________________________________

1. I am a U.S. citizen or an alien admitted for permanent residence. 4. I have never been convicted of a felony.
2. I have been a resident of Illinois for at least 30 days. 5. I am able to read and write the English language.
3. I am age 18 or older. 6. I have never had a notary public commission revoked.
I do solemnly affirm, under the penalty of perjury, that the answers to all statements on this application are true, complete and correct; that I have carefully read
the notary law of the State of Illinois; and that if appointed and commissioned as a notary public, I will perform faithfully, to the best of my ability, all notarial acts in
accordance with the law. Further, my signature below authorizes the Office of the Secretary of State to conduct a background verification to confirm the assertions
and information provided herein.
Printed Name as you AFFIX NOTARY SEAL HERE
want Commissioned: _________________________________________________________________

Signature of Applicant
as Printed Above: ____________________________________________________________________
Notary Public Signature:_______________________________________________________________
Witnessed and Affirmed this ____________ day of _____________________, 20 ________________

NOTARY PUBLIC BOND
THIS BOND MUST BE WRITTEN BY A COMPANY QUALIFIED WITH THE ILLINOIS DEPARTMENT OF INSURANCE TO WRITE SURETY BONDS IN THE
STATE OF ILLINOIS. The Office of the Secretary of State does not recommend any particular bonding or insurance company.
Know all by these presents that we _______________________________________________________________________________as principal/applicant and
____________________________________________________________________ are held firmly bound unto the People of the State of Illinois, in the penal
sum of FIVE THOUSAND DOLLARS ($5,000), for the payment of which, well and truly to be made, we bind ourselves, our heirs, executors, administrators and
assigns jointly and severally, firmly by these presents.
THE CONDITION OF THE ABOVE OBLIGATION IS SUCH THAT, whereas, the above bound principal/applicant has applied for appointment by the Secretary
of State of the State of Illinois as a Notary Public for a four-year term.

Now, if said principal/applicant shall truly and faithfully perform and discharge the duties of said office of Notary Public, in all things according to law, then the
above obligation to be null and void, otherwise to remain in full force and virtue in law. The term of this bond is from the effective date of the principals’s/applicant’s
commission to the expiration date of the same.

x ______________________________________________________ x ______________________________________________________
Signature of Principal/Notary Public Applicant Signature of Authorized Representative of Surety Company
BOND NUMBER AFFIX CORPORATE SEAL HERE
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Travelers Casualty and Surety Company of America

One Tower Square, Hartford, Connecticut 06183

NOTARY PUBLIC ERRORS AND OMISSIONS POLICY
Policy No ____________
Term Premium: ____________
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Policy Effective Date ____________

TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA (the “Company”) will pay on behalf of
______________________________________________ of ________________________________________________________
(the “Insured”), all sums which the Insured shall become obligated to pay by reason of liability for breach of duty while acting as a duly
commissioned and sworn Notary Public, claim for which is made against the Insured by reason of any negligent act, error or omission, committed or
alleged to have been committed by the Insured, arising out of the performance of notarial service for others in the Insured’s capacity as a duly
commissioned and sworn Notary Public.

POLICY PERIOD: This policy applies only to negligent acts, errors or omissions which occur during the Policy Period and then only if
claim, suit or other action arising therefrom is commenced within the applicable Statute of Limitations pertaining to the Insured. The Policy Period
commences on the Effective Date hereof and terminates upon the expiration of the Insured’s commission as a Notary Public unless cancelled earlier
as provided in this policy. This policy is not valid for more than one commission term.
LIMIT OF LIABILITY: The liability of the Company shall not exceed in the aggregate for all claims under this insurance the amount of:
_________________________________________________________________________________________ DOLLARS (________________).
In addition to the limit of liability and in accordance with the other provisions of this policy, the Company will pay costs and expenses paid and
incurred in investigating, contesting or settling liability in an amount not to exceed, in the aggregate, one-half of the limit of this policy.

INSURED’S DUTIES IN THE EVENT OF OCCURRENCE, CLAIM OR SUIT:
(a) Upon knowledge of any occurrence which may reasonably be expected to result in a claim or suit, written notice containing
particulars sufficient to identify the Insured and also reasonably obtainable information with respect to the time, place and circumstances thereof, and
the names and addresses of the potential claimant and of available witnesses, shall be given by or for the Insured to the Company or any of its
authorized agents as soon as practicable, but in no event longer than forty-five (45) days after discovery.
(b) If claim is made or suit is brought against the Insured, the Insured shall immediately forward to the Company every demand,
notice, summons or other process received by him or his representative.
(c) The Insured shall cooperate with the Company and, upon the Company’s request, assist in making settlements, in the conduct of
suits and the Insured shall attend hearings and trials and assist in securing and giving evidence and obtaining the attendance of witnesses. The
Insured shall not, except at his own cost, voluntarily make any payment, assume any obligation or incur any expense except with the prior written
consent of the Company.
EXCLUSIONS: Coverage under this policy does not apply to any dishonest, fraudulent, criminal or malicious act or omission of the
Insured.

OTHER INSURANCE: If the Insured has other insurance against a loss covered by this policy, the Company shall not be liable under this
policy for a greater proportion of such loss, cost and expenses than the limit of liability stated in this policy bears to the total limit of liability of all
valid and collectible insurance against such loss.
CANCELLATION: The insured may cancel this policy at any time by mailing or delivering to us advance written notice of cancellation.
The company may cancel this policy by mailing or delivering to the insured written notice of cancellation at least 10 days before the effective date of
cancellation if we cancel for nonpayment of premium or 30 days before the effective date of cancellation if we cancel for any other reason. If we
cancel, the premium refund will be pro rata and if the insured cancels, the refund may be less than pro rata. The cancellation will be effective even if
we have not made or offered a refund.

IN WITNESS WHEREOF, the Company has caused this Policy to be signed by its authorized Company officers at Hartford, CT.

____________________________________________ ___________________________________________
President Corporate Secretary

EO1001 (03-04)
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ISSUED BY: POLICY NO:
ISSUED TO:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION/NONRENEWAL – ILLINOIS
FULL CANCELLATION – INSURER
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It is agreed that:

1. The policy provisions regarding cancellation by the Company are deleted and replaced with the following:
A. CANCELLATION OF POLICIES IN EFFECT FOR 60 DAYS OR LESS
(a) If this Policy has been in effect for 60 days or less and is not a renewal of a policy we issued, we may cancel this
Policy for any reason by mailing to the entity named in Item 1 of the Declarations written notice of cancellation at
least 10 days before the effective date of cancellation if we cancel for nonpayment of premium or at least 30 days
before the effective date of cancellation if we cancel for any other reason.

B. CANCELLATION OF POLICIES IN EFFECT FOR MORE THAN 60 DAYS
If this Policy has been in effect for more than 60 days, or is a renewal of a Policy we issued, we may cancel only for one
or more of the following reasons:
(a) Nonpayment of premium;
(b) Policy was obtained through material misrepresentation;
(c) Any insured violated the terms and conditions of the policy;
(d) The risk originally accepted has measurably increased;
(e) Certification to the Director of loss of reinsurance; or
(f) Determination by the Director that continuation of the policy could place insurer in violation of law.

We will mail written notice of cancellation under this item B., to the entity named in Item 1 of the Declarations at least:
(1) 10 days before the effective date of cancellation if we cancel for nonpayment of premium; or
(2) 60 days before the effective date of cancellation if we cancel for a reason described in B.(b) through (f) above.

2. The following is added and supersedes any other provision to the contrary:

NONRENEWAL
A. If we decide not to renew this Policy, we will mail written notice of nonrenewal to the entity named in Item 1 of the
Declarations, with an exact copy to the agent or broker of record, at least 60 days before its expiration date, or its anniversary
date if it is a Policy written for a term of more than one year or with no fixed expiration date.

3. Proof of mailing is sufficient proof of notice. We will mail cancellation and nonrenewal notices to the last address known to the
Company.

Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, exclusions or limitations of the
above mentioned policy, except as expressly stated herein. This endorsement is effective at the inception date stated in the
Declarations and this endorsement is part of such policy and incorporated therein.

ILT-5026 (06-04)
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ISSUED BY: POLICY NO:
ISSUED TO:

THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.

CANCELLATION/NONRENEWAL – ILLINOIS
CANCELLATION FOR NONPAYMENT OF PREMIUM
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It is agreed that:

1. The policy provisions regarding cancellation by the Company are deleted and replaced with the following:
A. We may cancel this Policy for nonpayment of premium by mailing to the entity named in Item 1 of the Declarations written
notice of cancellation at least 10 days before the effective date of cancellation.

2. The following is added and supersedes any other provision to the contrary:

NONRENEWAL
A. If we decide not to renew this Policy, we will mail written notice of nonrenewal to the entity named in Item 1 of the
Declarations, with an exact copy to the agent or broker of record, at least 60 days before its expiration date, or its anniversary
date if it is a Policy written for a term of more than one year or with no fixed expiration date.

3. Proof of mailing is sufficient proof of notice. We will mail cancellation and nonrenewal notices to the last address known to the
Company.

Nothing herein contained shall be held to vary, alter, waive or extend any of the terms, conditions, exclusions or limitations of the
above mentioned policy, except as expressly stated herein. This endorsement is effective at the inception date stated in the
Declarations and this endorsement is part of such policy and incorporated therein.

ILT-5027 (06-04)