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Agent Registration  

Important:  You must have your APFC Agent Number to register
If you are not an Insurance Agent or Broker, DO NOT complete this form
   
Only one registration per Agency

All information will be kept confidential.    * = Required Field

      AGENCY INFORMATION
  Agency Name*  
APFC Agent Number*  
Agency Contact Name*
One Name per Agency		  
  Address*  
  City, State & Zip*           
  Phone*                          Fax  
  Agency Email*    
One Master Email per Agency
Used for email to Agency & Password retrieval. 
All Customer Reports and communications will be sent to this email address only.
 
  Agency Password*   6 to 10 Letters or Digits only, Case Sensitive
One Password for all Agency Staff to Logon with
 
  Retype Password*  
 


Agency Checking Account Information
Only needed to submit payments collected from your customers
Not needed for web access to Customers Accounts  

  Bank Name  
  Bank Routing Number  
  Checking Acct Number  
  Name on Checking Acct  
  Address on Checking Acct  
  City, State & Zip on Acct         
       

           

Please press button only once.
You will be directed to a page confirming receipt of your registration.