By signing this form, I
First NameLast NamePhone NumberEmail AddressAgency/Brokerage Name
, 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.
Date of AuthorizationAuthorization Signature/Title
Please type your electronic signature for electronically signed finance agreements below.
NameInitials
