ARIZONA PREMIUM FINANCE CO.
P.O. BOX 30190   PHOENIX, AZ 85046-0190 
Fax to 800-273-9979
 

APFC Account Number

  
 

ADDITIONAL PREMIUM REQUEST
Named Insured  
Address  
City, State, Zip  
Home Tel  

Wk Tel

  
Policy No. Insurance Co. Additional Premium Additional Down Payment Additional Amount Financed
         
         

ADDITIONAL DOWN PAYMENT REQUIRED
    ANNUAL POLICIES  
  25% WITHIN 30 DAYS OF THE POLICY INCEPTION
  35% WITHIN 60 DAYS OF THE POLICY INCEPTION
  45% WITHIN 90 DAYS OF THE POLICY INCEPTION
  55% WITHIN 120 DAYS OF THE POLICY INCEPTION
  65% WITHIN 150 DAYS OF THE POLICY INCEPTION
    SIX MONTH POLICIES  
  35% WITHIN 30 DAYS OF THE POLICY INCEPTION
  45% WITHIN 60 DAYS OF THE POLICY INCEPTION
I request that the above stated additional amount financed be added to my existing loan.  I agree and acknowledge that I am bound by all the terms and conditions of the original premium finance agreement.

Date

  

Insured's Signature

  
 

Agent's Signature

  

FOR APFC USE ONLY

Remaining # of Payments

  

Next Due Date

  
 
APFC must receive this fully executed form along with the required Down Payment, and the Insured's Account must be current before we will process this request.