Agency/Brokerage Profile
Stonemark Representative: Trade show/Event: Other:
Licensed Agent/Broker Name
D.B.A. (if applicable)
Date Established $ Confirm This is the Head OfficeYesNo
Number of Branch Offices Separate Banking for any Branches?YesNo
Accounting Email(s)
Street AddressCityProvince/TerritoryAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPostal Code
Same as previous
Primary Contact Name Website
Phone
Email
Reinstatement Email(s) Cancellations Email(s) Missing Policy # Report Email(s) All Other Notices Email(s)
Total Number of Employees
First Name Last Name Email -+
Annual Estimated Premium Volume($) $ % Commercial LinesAnnual Estimated Number of Policies
% Premiums Financed % Personal LinesExpected Largest Amount Financed $
Average Premium Per Policy ($) $
First NameLast Name Select for Electronic Signature
By signing below, I acknowledge and authorize Stonemark, Inc. to perform a scan of my signature and electronically 'stamp' or 'sign' the finance agreement requiring my signature and that of the borrower/insured. Such documents may include finance agreements, change of address, endorsement request and other related documents, renewals or other such authorized changes.
I also understand that I may revoke this signature authorization at any time by sending a request in writing (email correspondence is acceptable) to Stonemark, Inc.
Please type your electronic signature for electronically signed finance agreements below.
NameInitials
