Any such undertaking shall be in a form to be prescribed by the Commissioner of Insurance, and subject to such regulations as he shall from time to time prescribe in regard thereto, and shall state the following:
a. The name and address of the automobile club or clubs or automobile association or associations with respect to guaranteed arrest bond certificates of which the surety company undertakes to be surety;
b. The unqualified obligation of the surety company to pay the fine or forfeiture in an amount not to exceed $500.00 of any person who, after posting a guaranteed arrest bond certificate with respect to which the surety company has undertaken to be surety, failed to make the appearance for which the guaranteed arrest bond certificate was posted.