Agency Profile - Consolidated Premium Partners, LLC

AGENCY INFORMATION

Agency Name*

Physical Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is Mailing Address Different from Physical?

Yes
No

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone*

Tax ID*

Website (URL)

Agency License #*

Year Established*

# of Employees*

Annual P&C Volume*

Amount Financed*

Avg. Finance Size ($)*

PREMIUM FINANCE AGENCY CONTACT INFORMATION

Name*

Email*

Phone*

Name

Email

Phone

AGENCY PRINCIPAL INFORMATION

Name*

Email*

License #*

DOB*

Name

Email

License #

DOB

OTHER INFORMATION

Previous or Current Finance Co(s) / Frequently Used GA's or Carriers

Company Name*

Year Left (if any)*

Name*

City/State*

Company Name

Year Left (if any)

Name

City/State

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding it is to be used to determine the amount and conditions of the credit to be extended. I further understand and agree to return all Unearned Fees paid to me for financing the premiums in the event of cancellation of the policy(s) for any reason prior to loan maturity. Such Return shall be due and payable within 30 days.

Signature*

Date*