Connect Capital Agency Premium Finance Application

Agency Name
Agency Address (If PO Box list street address)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Additional Agency Locations

(If Any)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact Full Name

First NameLast Name
Title/Position
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Agency License #
References

(Include Direct Carrier Appointments)
Name of Carrier/General Agent,

Contact Name,

Phone Number,

and Email
Name of Carrier/General Agent,

Contact Name,

Phone Number,

and Email
Name of Carrier/General Agent,

Contact Name,

Phone Number,

and Email
Ownership

(Include all Owners, Officers, and Partners. Attach a seperate sheet if necessary)
Name

Title

% of Ownership
Name

Title

% of Ownership
Name

Title

% of Ownership
File Upload

Cancelof
Operations
Total P&C Volume
% of Personal
% of Commercial
Annual Premium Volume
Average Size Account
Type of Coverage Financed
Concentration in any Industry(ies)
Current Premium Financing Vendor
Total Amount Premium Financed
Is Your Agency Part of a Cluster Group?
Agency Management System Currently Used
Total Number of Employees
Signature
Date

MonthDayYear
Date
Should be Empty:

Additional Agency Locations