Insurance Agent/Agency Questionnaire
About the Buying/Refinancing Agent:
Name:
SSN:
DOB:
Home Address:
City
Telephone: (
)
(
Home Phone
State
)
(
Home Fax
Zip
)
Mobile Phone
E-mail Address:
How many years insurance experience do you have?
How many with Allstate?
Are you a licensed Allstate agent?
If so, when were you licensed?
Are you an R 3001 Allstate agent?
If so, since when?
Are you life insurance licensed?
If so, when were you licensed?
Are you Series 6-63 licensed?
If so, when were you licensed?
Are you an approved Allstate agency buyer?
If so, when were you approved?
Have you acquired any books of business in the last 12 months?
If so, how many?
Please complete the following if you currently own an Allstate agency:
Name of Agency:
Legal Form of Agency (corporation, dba, etc.):
Agency Address:
City
Phone/E-mail: (
)
Office Phone
Year agency was established:
Do you have any debt on your agency?
How many licensed staff do you employ?
(
State
Zip
)
Office Fax
E-mail Address
Length of your ownership:
If so, what is the amount?
How many unlicensed staff?
About the Agency Being Purchased/Refinanced:
Owner’s Name:
PPC LOAN • 9303 New Trails Drive, Suite 375, The Woodlands, TX 77381 • 800.456.2779 • 281.419.8309 (fax) • [email protected]
Page 2 of 2, PPC LOAN Insurance Agent/Agency Information Questionnaire
Name of Agency:
Legal Form of Agency (corporation, dba, etc.):
Agency Address:
City
Phone/E-mail: (
)
(
Office Phone
State
Zip
)
Fax
E-mail Address
When was the agency established?
How long has the seller owned it?
Is it an R 3001 Allstate agency?
If so, since when?
Is there any debt on the agency?
What is the agency’s selling price?
What is the owner’s reason for selling?
How many licensed staff are employed at the agency?
How many unlicensed staff?
If this is a refinancing, when was the book of business transferred?
Please complete the following if you have acquired another book of business in the past 12 months:
Seller’s Name:
Name of Agency:
Legal Form of Agency (corporation, dba, etc.):
Agency Address:
City
Purchase price of agency:
Date the book was transferred:
Amount financed:
Interest rate (APR) on the loan :
Monthly payment:
Number of months on the loan:
State
Zip
Collateral provided:
When was the agency established?
How long had the seller owned it?
Was it an R 3001 Allstate agency?
If so, since when?
What was the owner’s reason for selling?
(Please photocopy this sheet if needed to provide information about other books of business
acquired in the last 12 months.)
PPC LOAN • 9303 New Trails Drive, Suite 375, The Woodlands, TX 77381 • 800.456.2779 • 281.419.8309 (fax) • [email protected]