Hillton Finance Bank | New Agent Application

Please provide the information requested on this application and complete and sign the disclosure provided below. Please attach documents.

Agency Name*

DBA Name (if applicable)

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone #*

Fax #*

Email Address*

Date Agency Established*

How Long Under Current Ownership*

Agency Ownership Structure

Corporation
Partnership
Sole Proprietorship
LLC

Principal*

Title*

% of Ownership*

Multiple Principals?

Yes

Principal

Title

% of Ownership

Principal

Title

% of Ownership

Current Volume of Premiums

Annual Premium Volume ($)*

Annual Number of Policies*

Annual Premium ($)*

% Premiums Financed*

% Cancellation Frequency Expect*

Expected Largest Amount Financed*

Describe types of insurance business the agency desires to finance:*

Does the agency write policies for any cannabis-businesses? If so, briefly describe the business types and the due diligence procedures the agent conducts to ensure all cannabis related operations follow the guidelines as set forth by Federal Law.

Producers Able to Quote Financing Options

Name:*

License #*

Email Address:*

More than one producer?

Yes

Name:

License #:

Email Address:

Name:

License #:

Email Address:

Banking Reference

Name of Bank with Whom the Agency Does Business:*

Name of Bank Office:*

Address:*

Phone Number:*

Credit Questionnaire

Are there any lawsuits, judgements, liens, or foreclosures pending against the business or principal owners?*

Has the business or any of its affiliates or principal owners ever filed for bankruptcy including Chapters 7,11, or 13?*

Is the business or any of its affiliates or principal owners currently a party to a lawsuit?*

Has the business or any of its affiliates or principal owners had a license or permit suspended, restricted or revoked?*

Please provide the following:

• Copy of valid agency license for agency • Copy of agency’s E and O insurance policy • List of primary carriers • List of primary managing general agents and surplus lines agents that you use • Name of account managers in your office • States in which you write most of your policies

Upload Documents

Drop files here or

Max. file size: 30 MB, Max. files: 4.

I/We hereby: (a) represent and warrant the accuracy of the information provided on this document; (b) authorize Hillton Finance Bank, LLC to verify the accuracy of the information contained wherein, and to obtain business as well as personal credit information; and authorize lender to utilize a customer credit report from time to time in connection with the extension or continuation of the business.

Name of Agency*

By:*

Principal #1

Name*

First Last

Social Security #:*

Date of Birth*

Signature

Principal #2

Name

First Last

Social Security #:

Date of Birth

Signature*