If you are adding a new policy, please call 800-955-0083This form can only be used for existing policiesInsured*Effective Date of Policy*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Select one of the following:*My Account # begins with 1080My Account # begins with 1070My Account # begins with 1071Account #*Account #*Account #*Effective Date of Endorsement*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Agent****NEW POLICIES CAN NOT BE ADDED WITH THIS FORM.*** ***ADDITIONAL INSUREDS AND AUDITS CAN NOT BE FINANCED.***Policy 1Policy NumberCarrierManaging Gen. Agt.Premium $(Down Payment ‡) $Amount Financed $Policy 1Policy NumberCarrierManaging Gen. Agt.Premium $(Down Payment ‡) $Amount Financed $Policy 1Policy NumberCarrierManaging Gen. Agt.Premium $(Down Payment ‡) $Amount Financed $I, being the insured or an officer of the insured if insured is a company. authorize PFA to add the additional amount financed listed above to my account balance along with any additional finance charge/interest allowable by law.Electronic Signature of authorized agent* First Last Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(Down Payment ‡) Down payments are based on the elapsed period of time from the effective date of the endorsement to the date endorsement request is made: 0-30 days, please collect 25% down payment 31-60 days, please collect 40% down payment 61 days or more, please collect 50% down payment
