Agent Registration - Arizona Premium Finance Co.

		*Arizona Premium Finance Co.*
		....The Driving Force in Premium Finance 800-873-2732

Agent Registration

Important: You must have your APFC Agent Number to register
If you are not an Insurance Agent or Broker, DO NOT complete this form

Only one registration per Agency

All information will be kept confidential. * = Required Field

Agency Information

Agency Name*
APFC Agent Number*
Agency Contact Name* One Name per Agency
Address*
City, State & Zip*	,
Phone*	555-444-1234 Fax
Agency EMail*	One Master Email per Agency Used for email to Agency & Password retrieval
Agency Password*	6 to 10 Letters or Digits only, Case Sensitive One Password for all Agency Staff to Logon with
Retype Password*
Agency Checking Account Information Only needed to submit payments collected from your customers Not needed for web access to Customers Accounts
Bank Name
Bank Routing Number
Checking Acct Number
Name on Checking Acct
Address on Checking Acct
City, State & Zip on Acct	,

Please press button only once.
You will be directed to a page confirming receipt of your registration.