*If policy is cancelled by client or premium finance company, will the insurance company honor the requested cancellation date
or
will additional notices days be added? If applicable, how many additional days’ notice are required?
Commercial Lines Premium Finance Quote Request Form
Named Insured: ___________________________________ Agency Name: _________________________________________
Mailing Address: ____________________________________ Agent Code
(if available): ____________________________________
City, State and Zip Code: _____________________________ City and State:___________________________________________
Physical Address
(if different): ___________________________ Requested By: __________________________________________
Phone Number: ____________________________________ Phone Number: __________________________________________
Email Address: _____________________________________ Email Address: __________________________________________
Additional Considerations:
1. Is this a renewal for your agency? Yes No
2. Is this Insured currently in receivership or under bankruptcy protecti
on?
Yes No
3. Is this a marijuana-related business
?
Yes No
Schedule of Policies
Insurance
Company
Intermediary
Effective
Date
Coverage
Type
Policy
Number
Term
Auditable
(Y / N)
Cancel
Earned
Policy
Premium
Taxes and
Earned
% $ $ $
% $ $ $
% $ $ $
% $ $ $
% $ $ $
Special Terms Requests:
Down Payment: ______________________
Number of Payments: __________________
Please return completed Quote Request to: quotes@stetsonfunding.com
Grand Total: $
