Agency ProfileLicensed Agent Name*D.B.A (if applicable)Select one of the following:*Federal Tax I.D. #Social Security NumberFederal Tax I.D. #*Social Security Number*Agency Licenses*Agency License #Domiciled State License Held Date Agency Established*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is This The Home Office?*YesNoNumber of Branch OfficesType of Business*Proprietorship Partnership Corporation LLC Physical Address of Office Applying* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address of Office Applying* Same as previous Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Fax*Email* Notice PreferencesReinstatement*E-mailMailBothEmail Cancellations*E-mailMailBothEmail Missing Policy # Report*E-mailMailBothEmail All Other Notices*E-mailMailBothEmail ***Total Number of Licensed Producers***This Office# of ProducersAll Branch Offices# of ProduceresCurrent Volume of PremiumAnnual Premium Volume ($)*Annual Number of Policies*Average Premium ($)*% Premiums Financed*Expected Largest Amount Financed*AuthorizationBy signing this form, IName* 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.NameInitialsDate: 09/25/2021
