Installment Agreement for Unpaid Premium
THIS FORM IS ADOPTED BY THE MARYLAND INSURANCE COMMISSIONER.
(October/2017)
I (we), the undersigned person(s), jointly and severally (together and separately), promise to pay to the order of:
____________________________________________________________________________ (Bail Bondsman) the
principal sum of _______________________ Dollars ($ ) owed for the bail bond
of:_______________________________________________ ("Defendant") in Criminal Case No. __________________
in the District/Circuit Court of ______________ City/County, Maryland at the address shown below in the Bail Producer
Name and Agency Box according to the following payment plan, which consists of a total of ________________
installment payments. Payments in the amount of $ ________________ shall be paid:
Weekly Bi-Weekly Monthly
Payments shall continue until the balance due is paid in full. The first payment is due on: _______________________
and the last payment is due on: _______________________________.
1. This installment agreement does not include a confessed judgment clause that waives a consumer’s right to assert
a legal defense to an action under this installment agreement.
2. This installment agreement continues in force until all payments have been paid in full.
3. This one page installment agreement represents the entire agreement. Any changes or modifications to this
installment agreement must be in writing and signed by both parties.
I (we) agree to all terms and conditions of this agreement and acknowledge receipt of a copy of this agreement and a
receipt showing the amount of the down payment made.
Bail Bondsman Producer Person(s) Agreeing to Pay:
Signature: _______________________________________ Signature: _______________________________________________
Print Name: _____________________________________ Print Name: ______________________________________________
Date: __________________________________________ Date: ____________________________________________________
Producer License #:_______________________________ Signature: ________________________________________________
Print Name: ______________________________________________
Date: ____________________________________________________
NOTICE TO CONSUMERS
This installment agreement continues in force until all payments have been paid in full. This means that YOU MUST
CONTINUE TO PAY THE FULL BALANCE OWED even if the Defendant is arrested again and taken into custody on this
matter or any other criminal matter, or the case is decided before you have finished paying the total balance due, or the case is
dismissed, or the Defendant does not show up for court.
Bail bond installment contracts are regulated by the Maryland Insurance Administration, 200 St. Paul Place, Suite 2700,
Baltimore, MD 21202. Phone: 410-468-2000/ 1-800-492-6116 (toll free)/ 1-800-735-2258 (TTY) www.insurance.maryland.gov
.
BAIL BONDSMAN NAME AND AGENCYNAME
[Include: name, address, phone number(s), and license number(s) for both bail bondsman and agency.]
