PRO Premium Finance, Inc.

Agency Information Request Form

Agency Name:

Contact Person:

Street Address:

City:

County:

State:

Zip:

Mailing Address:
(Skip if same as above)

Phone:

Fax:

Email:

Agency Opened: (Year)

Is Agency?:

Individual

Partnership

Corporation

Does the agency have
more than one location?:

Yes No

If Yes, How Many?:

How did you hear of
PRO Premium?:

Password of Choice
(Max of 10 characters):

How would you like to receive
your copies of customer notices
(i.e. late; cancel; etc.)?:

Email Mailed to Agency

How would you like to receive
your bi-weekly notice of accounts
to be cancelled?:

Email Fax

Owners/Officers: (Include All)

Name of Licensed Agent:

State License Number for Agent:

Agency State License Number:
(if applicable)

E. & O. Carrier:

Company Name:

Policy #:

Exp. Date:

Agency Production:

Total P&C Volume:

Estimated Annual/Monthly
Financed Premium:

Personal Lines:

Commercial Lines:

Previous/Existing
Finance Company(ies):
(Seperate with a comma)

Agency Management System:

QQ Binding Password:
(If Using QuickQuote
Rating Software)

Does your agency bind
policies on TruePremium.com?:

Yes No

Company/GA appointments currently held:

Names: