Agent Application

Agency Licenses*

Agency License #	Domiciled State License Held

Date Agency Established*
Is This The Home Office?*
- Yes
- No
Number of Branch Offices
Type of Business*
- Proprietorship
- Partnership
- Corporation
- LLC
Physical Address of Office Applying*
Street Address City State ZIP Code
Mailing Address of Office Applying*
Same as previous

Street Address City State ZIP Code
Phone*
Fax*
Email*
Notice Preferences
Reinstatement*
- E-mail
- Mail
- Both
Email
Cancellations*
- E-mail
- Mail
- Both
Email
Missing Policy # Report*
- E-mail
- Mail
- Both
Email
All Other Notices*
- E-mail
- Mail
- Both
Email
***Total Number of Licensed Producers***
This Office
# of Producers
All Branch Offices
# of Produceres
Current Volume of Premium
Annual Premium Volume ($)*
Annual Number of Policies*
Average Premium ($)*
% Premiums Financed*
Expected Largest Amount Financed*
Authorization
By signing this form, I
Name*
First Last
, 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.
Name
Initials
Date: 06/15/2019

Agency Profile