Retail Agents

WHY IS USPF PREFERRED BY AGENCIES NATIONWIDE?

We give our agents a competitive advantage by offering – professional and courteous service, easy-access software, creative financing solutions, and great rates and terms; all supported by the most experienced sales and service teams in the industry.

WHY DO THE BEST AGENTS WORK WITH USPF?

It’s our service! We work with the largest Property and Casualty agencies in North America, but our tradition of personalized service is that of a boutique company. We deliver a user-friendly, path of least resistance finance option to our agent-clients along with competitive rates. Pricing and terms are best in the industry. YOU’LL SEE!

AGENT REGISTRATION

Primary Contact Name	Primary Contact Email	Primary Contact Phone Number
Agency Name	Agency Physical Address	Agency City
Agency State	Agency Zip Code	Years in Business
Number of Employees	Estimated Total Annual Premiums	Estimated Annual Finance Volume
Class of Business/Specializations (Hold CTRL to section multiple options)	If OTHER, Indicate Class of Business/Specializations	Estimated Annual Number of Contracts
Current Finance Vendor	If OTHER, Indicate Current Finance Vendor	Percentage of your business is commercial?
Does your agency do business with any Carrier/Managing General Agent in which you have over 5% ownership? YesNo		If YES, Indicate the Carrier/Managing General Agent Name
Agency Management System	Would you like to automate finance agreements from within your agency management system? YesNo
Electronic Notice Selection By checking this box and signing below, you understand that you OPT IN to receive electronic notices from US Premium Finance. You knowingly and voluntarily give up and waive all rights to receive written notices delivered by U.S. Mail and agree that receipt of said notices delivered by electronic transmission satisfies any legal notice requirements. Consent to receive electronic notices may be withdrawn in writing at any time.By checking this box and signing below, you understand that you OPT OUT of receiving electronic notices. You will only receive notices from US Premium Finance in written form delivered via U.S. mail.
Market References
Name of Insurance Company/General Agent	City	State
Direct Contact Name	Direct Contact Number	Direct Email
Name of Insurance Company/General Agent	City	State
Direct Contact Name	Direct Contact Number	Direct Email
Please upload your Agency State License	Please upload your Producer State License	Please upload your Agency W-9 Form
Please upload your Errors & Omissions Document	Other	Other
How did you hear about us?	If OTHER, what lead you to us?
CERTIFICATION: The undersigned Agent/Broker, hereinafter referred to as “Agent”, hereby represents and warrants that all information listed in this agreement has been accurately represented. US Premium Finance reserves the right to amend any terms or rates provided based on inaccurate information. Agent further agrees to indemnify US Premium Finance against any damages, costs or expenses incurred in connection with any untrue, misleading or fraudulent representation or warranty made by Agent hereunder. I have read and acknowledge the Certification statement above.
Name of Form Completer