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Arizona Premium Finance Co., Inc. 12406 N. 32nd Street, Suite 110, Phoenix, AZ 85032 Tel: 800-873-2732 x 140 Fax: 602-867-3480 AGENCY PROFILE & APPLICATION TO FINANCEAgency Name: _____________________________________________________________________________ Off. Mgr.: _________________________________________________________________________________ Address: __________________________________________________________________________________ Mailing Address: ___________________________________________________________________________ Telephone: _____________________________________ Fax: ______________________________________ Email Address: ___________________________________________________________ Type of Agency: (Check One) _____ Sole Proprietorship _____ Partnership _____ Corporation How Long in Business: ___________ How Long at Location: __________ Other Locations: ___________________________________________________________________________ Number of Employees: _________ Total Agency Volume: $________________________________________ Book of Business: Commercial __________% Personal __________% Principal Companies Represented Company: ________________________________________________ Telephone: ____________________ Address: ________________________________________________________________________________ Company: ________________________________________________ Telephone: ____________________ Address: ________________________________________________________________________________ Company: ________________________________________________ Telephone: ____________________ Address:
________________________________________________________________________________ State(s) of Operation: _______________________________________________________________________ Department of Insurance License #: ____________________________________________________________ Agents E&O Carrier _____________________________________ Policy No: ________________________ Broker Bond: Company:___________________________________ Bond
Number: _____________________ Computer Systems Type of System: _______________________ Modem:
_____________________ Printer: _________________ Agency Bank Affiliation Name of Bank: _______________________________________ Tel: ________________________________ Address: _________________________________________________________________________________ Premium Trust Acct. No. _________________________Checking
Acct. No. ___________________________ Principals Name: __________________________________ Title: _________________ SSN: ____________________ Name: __________________________________ Title: _________________ SSN: ____________________ Name: __________________________________ Title:
_________________ SSN: ____________________
Arizona Premium Finance Co., Inc. AGENCY PROFILE & APPLICATION TO FINANCE
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