By signing this form, IName* First Last Phone Number*Email Address* Agency 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 in applicable states. 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 Authorization*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Authorization Signature/Title*Please type your electronic signature below.Name*Initials* This iframe contains the logic required to handle Ajax powered Gravity Forms.
