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 IPFS Corporation 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 IPFS Corporation.
Please type your electronic signature for electronically signed finance agreements below.
NameInitials
Please continue to log in using your Stonemark credentials. For questions, please feel free to contact us at 800-955-0083