Allstate Loan Program Step 1 of 17 - Agency Information 5% Agency Name* Agency Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business Phone*Email Address* Business Type* Corporation Limited Liability Company (LLC) Sole Proprietorship Tax ID* History* Started from Scratch Purchased Agency Date of Purchase* MM slash DD slash YYYY Purchase Price*Date Established* MM slash DD slash YYYY Years of Insurance Experience* Number of Employees*Number of Producing Staff*Number of Support Staff* Requested Loan Amount*Requested Term* 3 Years 5 Years 7 Years 10 Years 15 Years Other Use of Proceeds*Please tell us about how you plan to use the loan proceeds e.g. working capital, technology upgrade, staffing, etc. Exact Name on Allstate R3001 Agreement* Allstate Agent ID* Allstate TPP Vesting Status* Fully Vested In-Vesting Allstate Vested TPP Amount*Allstate In-Vesting TPP AmountTermination Summary ReportThe Allstate Termination Summary Report can be found within DASH under Business Metrics. Please contact support if you need assistance locating or downloading this report. Drop files here or Select files Accepted file types: pdf, xls, xlsx, tiff, Max. file size: 256 MB. Annual Commission Revenue*Approx. Value of Agency*Commission Summary ReportThe Allstate Commission Summary Report (CSRP) can be found within DASH under Business Metrics. Please contact support if you need assistance locating or downloading this report. Drop files here or Select files Accepted file types: pdf, xls, xlsx, tiff, Max. file size: 256 MB. Do you have a Year-to-Date Profit & Loss Statement?* Yes No Upload Profit & Loss StatementPlease upload a copy of your Agency's profit and loss statement using the form below. If you don't have a current profit and loss statement, please select "No" above. Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlxs, tiff, Max. file size: 256 MB. Click Here to download a copy of our Profit & Loss Statement TemplateUpload Profit & Loss StatementOnce you've completed the Profit & Loss Statement, please upload a copy using the form below Drop files here or Select files Accepted file types: pdf, doc, docx, xlx, xlsx, tiff, Max. file size: 256 MB. Existing Lien on Book of Business* Yes No Amount of Existing Debt*Lender's Name Loan Maturity MM slash DD slash YYYY Interest Rate Secondary Lien on Book of Business* Yes No Amount of Existing Debt*Lender's Name Loan Maturity MM slash DD slash YYYY Interest Rate Borrower's Name* First Last Borrower's Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Residential Status* Rent Own Monthly Payment* Estimated Credit Score* Date of Birth* MM slash DD slash YYYY Mother's Maiden Name* Social Security Number* Have you ever filed for or taken bankruptcy?* No Yes Please explain about the bankruptcy*Are you a defendant in any suits or legal action* No Yes Please explain about the suits or legal action* Do you have a Personal Financial Statement* Yes No Upload Personal Financial Statement Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 256 MB. Please upload a copy of your Personal Financial Statement using the form below. If you don't have a personal financial statement, please select "No" above.Click Here to download a copy of our Personal Financial StatementUpload Profit & Loss Statement Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 256 MB. Once you've completed the Personal Financial Statement, please upload a copy using the form below. Co-Borrower?* Yes No Co-Borrower Name* First Last Co-Borrower Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Residential Status (Co-Borrower)* Own Rent Monthly Payment (Co-Borrower) Estimated Credit Score (Co-Borrower)* Date of Birth (Co-Borrower)* MM slash DD slash YYYY Mother's Maiden Name (Co-Borrower)* Social Security Number (Co-Borrower)* Have ever filed for or taken bankruptcy? (Co-Borrower) Yes No Are you a defendant in any suits or legal action? (Co-Borrower) Yes No Supporting DocumentsIn many cases, additional supporting documents may be required in order to approve your loan. To expedite the loan approval process, please upload any additional supporting document you have available. 2018 Business Tax Return 2018 Personal Tax Return 2017 Business Tax Return 2017 Personal Tax Return 2016 Business Tax Return 2016 Personal Tax Return Allstate Commission Payment Notification (CPN) Allstate Business Metrics Report Personal Financial Statement Resume or Bio of Applicant(s) Copy of Driver's License, Passport or State Issued I.D. Other Upload Supporting Documents Drop files here or Select files Accepted file types: pdf, doc, docx, tiff, png, jpg, xls, xlsx, Max. file size: 256 MB. PhoneThis field is for validation purposes and should be left unchanged.
