Arizona Premium Finance Co., Inc.
12406 N. 32nd 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

 

Arizona Premium Finance Co. 800-873-2732  ... The Driving Force in Premium Finance
 
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