Agency Profile
Licensed Agent Name
D.B.A. (if applicable)
Select one of the following: Federal Tax I.D. #Social Security Number
Federal Tax I.D. #
Social Security Number
Agency License # Domiciled State License Held -+
Date Agency Established
Is This The Home Office? YesNo
Number of Branch Offices
Type of Business ProprietorshipPartnershipCorporationLLC
Street AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code
Same as previousStreet AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code
Phone Fax Email
ReinstatementEmailMailBoth
Email
CancellationsEmailMailBoth
Missing Policy # ReportEmailMailBoth
All Other NoticesEmailMailBoth
# of Producers, This Office # of Producers, All Branch Offices
Annual Premium Volume ($) $ Annual Number of Policies Average Premium ($) $ % Premiums Financed Expected Largest Amount Financed $
By signing this form, I
First NameLast Name
, acknowledge and authorize Stonemark, Inc. to perform a scan of my signature and electronically 'stamp' or 'sign' the finance agreement requiring my signature and that of the borrower/insured in applicable states. Such documents may include finance agreements, change of address, endorsement request and other related documents, renewals or other such authorized changes.
I also understand that I may revoke this signature authorization at any time by sending a request in writing (email correspondence is acceptable) to Stonemark, Inc.
Please type your electronic signature for electronically signed finance agreements below.
NameInitials
