Agents Online Application to Finance

Arizona Premium Finance Co., Inc.
12406 N. 32^nd Street, Suite 110
Phoenix, AZ 85032
Tel: 800-873-2732 x 140 Fax: 602-867-3480

AGENCY PROFILE & APPLICATION TO FINANCE

Complete form and print form. Sign application.
Fax application and supporting documentation to 602-867-3480

Agency Name
Physical Address
City, State, Zip	, -
Telephone	- -
Fax	- -
Email
Mailing Address
City, State, Zip	, -
Office Manager
Type of Agency	Sole Proprietorship Partnership Corporation

How Long in Business

Years

How Long at Location

Years

Number of Employees

Annual Agency Premium $ Volume

Total Premium $ Financed Annually

No. of Finance Contracts per Month

Book of Business:

Personal

Commercial

Principal Companies Represented

Company

Telephone

- -

Company		Telephone	- -
Company		Telephone	- -

Licensing & Insurance

States of Operation

Department of Insurance License #

Agent's E&O Carrier

E&O Policy No.

Agency Principals

Name

Title

Name

Title

Name

Title

Please provide copies of your Agent and or Brokers License and
E & O Declarations Page (if covered). Sign this form below.

The undersigned Agent and or Principal, hereby warrants and agrees, that the above information is true and correct; that the agency will follow all underwriting instructions and procedures of Arizona Premium Finance Co., Inc. (APFC); and upon termination of a finance agreement or cancellation of any policy, will pay unearned premium and or unearned commission to APFC upon our demand.

__________________________________________	___________________________________
Signature of Agent	Title

Arizona Premium Finance Co., Inc.
AGENCY PROFILE & APPLICATION TO FINANCE