Thank you for completing this form. The information will be used to establish a relationship with your agency/brokerage and to provide appropriate programs together with the best possible service.

Asterisked information * is required, or you may complete the box with N/A. We will get back to you shortly.

Date: 02/07/12 AFCO CAFO Contact:


AGENCY/BROKERAGE INFORMATION
Agency/Brokerage: *
Address: *
City: *
State/Province: *
Zip/Postal: *
Phone: * E-Mail Address/Website: *


OWNERS/PRINCIPALS AND TITLES

  Name: Title:
1) * *
2)


AGENCY/BROKERAGE CONTACTS AND TITLES

  Name: Title:
1) * *
2)


How long in business?
*

Association Memberships:
      

Premiums Written Annually:
*
  Commercial %: % *   Personal %: %

Premiums Financed Annually:

Types of Insureds Financed:
      

Present Finance Facility:
      

Why Interested in AFCO CAFO:
      


INSURANCE COMPANIES REPRESENTED AND CONTACTS

  Insurance Company: Contact Name:
1) * *
2) * *
3) * *
4)
5)
6)


GENERAL AGENTS AND CONTACTS

  General Agent: Contact Name:
1) * *
2)
3)
4)


SELECT THE AFCO CAFO OFFICE YOU WOULD LIKE THIS INFORMATION DIRECTED TO *

Boston
Chicago
Edmonton
Dallas 		Kansas City
Miami
Montreal
New York 		San Diego
Seattle
Toronto