NEW AGENCY PROFILE

Premium Finance Brokerage, LLC
P.O. Box 623
Jarrettsville, MD 21084

Tel: 866-381-6501
Fax: 866-381-6502
Email: info@premiumfinancebrokerage.com

Legal Name:(Required)

DBA (if applicable):

Physical Address:(Required)

Street Address City State ZIP Code

Mailing Address:

Street Address City State ZIP Code

Phone:(Required)

Website:

Agency License #:(Required)

Tax ID:(Required)

Years in business:(Required)

# of Employees:(Required)

Agency Mgmt System:(Required)

Annual P&C Volume:(Required)

Amount Financed:(Required)

Current Premium Finance Company(ies):

Premium Finance Contact Name:(Required)

Title:(Required)

Phone:(Required)

Email:(Required)

Other Contacts:(Required)

Agency Principal Name:

Phone:

Email:

(Tip: Add more entries by clicking the + sign shown to the right.)

FREQUENTLY USED CARRIERS/GA’S:(Required)

Name:

City & State:

(NOTE: PLEASE PROVIDE A MINIMUM OF 3 ENTRIES. Tip: Add more entries by clicking the + sign shown to the right.)

Premium Finance Brokerage Representative Name(Required)