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To become an agent please choose one of the following options:

FILL OUT THE BUSINESS APPLICATION FOR TOTAL PREMIUM FINANCE AND DAB PREMIUM FINANCE BELOW

Please complete the information below, print and fax the signed form to us at (305) 556-4869 or email us at info@dabpremiumfinance.com Upon receipt, TOTAL PREMIUM FINANCE and DAB PREMIUM FINANCE will open a business profile in our system which will allow us to stablish a business relationship with your agency. Note: Please include a copy of your agency and producer license when submitting this application.

Agency Information
Legal Name of Agency *
DBA Name (If Different)
Physical Address *
City *
State *
Zip Code *
Mailing Address (If Different)
City
State
Zip Code
Telephone *
Fax
Email *
Primary Contact Person *
FederalTax ID# *
Agency License # *
Type of Business *
LLC Proprietorship Partnern Ship Corporation
Please attach a copy of your agency license *

E & O COVERAGE (Attach copy of Policy)
Company *
Policy # *
Expiration Date *
Please attach a copy of your Policy *

Bank References and ACH Details (not require)
Name of Bank
Address
City
State
Zip Code
Phone
Fax
Contact Person
Account#
ABA (Routing)#



TERMS, CONDITIONS AND AGREEMENT

Please read the following terms and conditions carefully. They govern your access and use of this website. By accessing or using this website, you agree to be bound by these terms and conditions and accept them in full.

I (we) acknowledge this information as true and correct. I (we) hereby authorize Total Premium Finance LLC ("TPF") and DAB Premium Finance (“DAB”) to verify any information from the references listed above and to obtain any business and personal credit information.

I (we) hereby authorize TPF and DAB to initiate credit entries and initiate, if necessary, debit entries and adjustments for any credit entries made in error to the Agency’s account indicated above and the depository named above, hereinafter called DEPOSITORY to credit and/or debit the same to such account. The authority is to remain in full force until TPF and DAB has received written notification of termination of authorization in such time and in such manner as to afford TPF and DAB and DEPOSITORY a reasonable opportunity to act on it.

The undersigned represents to TPF and DAB that the above information is accurate and that it will notify TPF and DAB immediately of any changes. The undersigned acknowledges that TPF and DAB are entering into a business relationship with the above-named agency ("Agency") in reliance of these representations.

The undersigned warrant(s) that the Agency will not be sold, transferred or otherwise liquidated until all liabilities to TPF and DAB have been satisfied. The undersigned, for and in consideration of TPF and DAB extending credit at his/her request to the Agency, hereby jointly and severally, personally guarantee(s) to TPF and DAB, its successors and assigns, the payment of any and all obligations of the Agency including the payment for any additional premiums, unearned commisions and/or the payment of any modifications required by the Insurance company for any reason whatsoever subsequent to the date of this agreement which shall not relieve the borrower or the Agency of any obligations hereunder. The undersigned hereby agrees to bind him/herself to pay TPF and DAB on demand any sum which may become due to TPF and DAB by the Agency whenever the Agency shall fail to pay the same. It is understood that this guaranty shall be a general, continuing, unconditional and irrevocable guaranty and indemnity for such indebtedness of the Agency. The undersigned hereby warrant(s) that any information provided to TPF and DAB on behalf of an insured seeking to obtain premium financing for an insurance policy issued and/or sold by Agency is true and correct to the best of its knowledge. The undersigned hereby accepts the obligation to obtain the authorized signature of the Insured on the contract submitted electronically or by fax to TPF and DAB for financing and to forward the ORIGINAL of the contract by mail, within 48 hours to TPF and DAB.

Agency understands that TPF and DAB retains the right to cancel or deny payment, at TPF and DAB’s option, of the corresponding draft if the same has not been timely received by TPF and DAB. Agency shall be liable for any loss up to the amount financed plus interest due and collection costs, including but not limited to: attorney’s fee, and court cost, suffered by TPF and DAB if due to Agency’s representations and/or certifications of information contained herein of statements made by producer and/or borrower. In the event that TPF and DAB engages attorneys to collect any amounts due, Agency and the undersigned agree to pay all costs of collection, including reasonable attorney’s fees, court costs and other collection costs incurred by TPF and DAB in recovering amounts due from the agent or broker in connection with any breach of the Agent/Broker representations and warranties and to indemnify TPF and DAB for any and all losses TPF and DAB incurs as a result of any error committed by the Agent/Broker in completing or failing to complete any portion of this agreement. THE AGENCY ACKNOWLEDGES THAT IT IS NOT AN AUTHORIZED AGENT NOR REPRESENTATIVE OF TOTAL PREMIUM FINANCE LLC and DAB PREMIUM FINANCE

GOVERNING LAW; SEVERABILITY: This Agreement shall be governed by and construed in accordance with the laws of the State of Florida. Each party agrees that venue for any legal action filed or commenced by either party arising out of, connected with, or relating in any way to this Agreement and/or the relationship between the parties shall lie exclusively in the courts located in Miami-Dade County, Florida or the United States District. Court for the Southern District of Florida in the State of Florida, U.S.A. Each party waives its right to a jury trial and hereby irrevocably submits and consents to the personal jurisdiction and exclusive venue of the aforementioned courts for any such legal action and waives lack of personal jurisdiction, improper venue or forum non-convenience as a defense to any such action. If any provision of this Agreement is determined by a tribunal of competent jurisdiction to be invalid or unenforceable, that provision shall be deemed severed from the remainder of the Agreement and the remaining provisions of this Agreement shall continue in full force and effect.

AGENT: TPF and DAB will not be responsible for any additional premium incurred by the addition of any coverage that is added outside of the original financial contract, unless previously approved by TPF and DAB. Furthermore, no deduction of unearned premium shall be deducted from TPF and DAB’s original contract premium funding for payment of any additional coverage added without TPF and DAB’s approval. Any additional coverage agreed upon amongst other parties, not including TPF and DAB and without TPF and DAB’s consent, is not TPF and DAB’s financial liability or responsibility and shall not be deducted from any unearned premium due to TPF and DAB from the original funding. Agent will assume full responsibility for any financial charges from insurance company for such additional coverage added to this contract.

AGENT: Agent shall be liable for all damages or losses sustained by TOTAL Premium Finance LLC and DAB Premium Finance caused by a) any misrepresentations made by Agent or Broker, and/or b) any negligence of Agent or Broker, in connection with the submission, processing, binding, amending, endorsing or cancelling of any policies procured for the Insured.

NOTE: ALL PARTIES WHO ARE PRINCIPALS IN THE AGENCY GREATER THAN 15.0% MUST SIGN THIS FORM.


NAME & ADDRESS OF PRINCIPALS OF THE COMPANY (Attach additional pages if necessary)
Name of Owner *
Title *
Address *
City *
State *
Zip Code *
SSN#
License# *
SIGNATURE(Required) *
Date

The above signed agency, individually and corporate agrees and acknowledges that this application legally applies for both TOTAL PREMIUM FINANCE and DAB PREMIUM FINANCE.