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COMMERCIAL LOAN APPLICATION 8888 Keystone Crossing, Suite 1700 Indianapolis, IN 46240 Phone: 866-625-3863 Any individual or corporate entity that will be a borrower or a guarantor of the proposed credit is defined as an Applicant. List each Applicant and authorized signor below. I am applying for individual/company credit in my/its own name and am relying on my/its own income or assets and not the income or assets of another person/entity as the basis of repayment of the credit requested. This is an application for joint credit with another person or entity

Applicant:______________________________________

Applicant:______________________________________

Applicant:______________________________________

Applicant:______________________________________

Loan Amount Requested: $________________________

General Information Business or Individual Name:___________________________________________

Federal Tax ID:______________________________

Primary Contact:_________________________________________________________

Email:______________________________________

Business Address:_______________________________________________________________________________________________________ City:_______________________________

State:______________________________ Zip:________________________________

County of Agency:________________________________ Agency Phone:_______________________ Type of Business

County of Residence:____________________________

Fax:_______________________________ Mobile:_____________________________

Sole Proprietor

Limited Liability Company

Corporation

Limited Liability Partnership

Original Start Date of Agency:_______________________

Date of Entity Creation:_________________Entity State:_______________

Date of Entity Ownership:______________________________ Are you a U.S. Citizen?

Yes

No

Partnership

Years of Insurance Industry Experience:______________ Are you a permanent resident Alien?

Yes

No

Principals Name:______________________________

Title:________________

Residence Address:______________________________ Home Phone:________________________

City:___________________ State:__________________ Zip:________

Date of Birth:________________________

Mobile Phone:________________________ Name:______________________________

Email Address:___________________________________ Title:________________

Residence Address:______________________________ Home Phone:________________________ Mobile Phone:________________________

Percentage of Agency Ownership:___________________

Percentage of Agency Ownership:___________________

City:___________________ State:__________________ Zip:________

Date of Birth:________________________ Email Address:___________________________________


If there are additional owners or business principals, please attach information

How did you hear about Oak Street

Advertisement Promo Code:________

Email or Internet Ad

Promo Code:______

Trade Association/Referral Partner

Google/Yahoo/Other Search Engine

Telemarketing

Other:______________________________

References Reference:_______________________________ Relationship_____________ Phone_________________ Years Associated___________________ Reference:_______________________________ Relationship_____________ Phone_________________ Years Associated___________________ Yes, I'd like to receive email updates and special offers from Oak Street

Commissions Carrier Name

Agent Number

Product Type

Billing

Annual Premium

Commission Rate

Are you appointed with a Managing General Agent (MGA):

Yes

No

If "Yes," please list the organization(s) you are contracted with:_________________________________________

Are you affiliated with an Aggretator, Cluster, or other affiliation?

Yes

No

If "Yes," please list the organization(s) you work with: ____________________________________________

Business Financial Obligation Do you or your business have any outstanding loans or guarantees against the business?

Yes

No

If "Yes," please provide the following information:

Creditor Name:_______________________________________ Phone:________________ Current Balance:_______________________________ Are there any unsatisfied judgments against you or the business?

Yes

No

If "Yes," please provide the following information:

Creditor Name:_______________________________________ Phone:________________ Current Balance:_______________________________ Have you or the business ever been declared bankruptcy in the past 14 years?

Yes

Location:______________________________________________________

No

If "Yes," please provide the following information:

Year:______________________________


Are there any outstanding state or federal tax obligations against you or the business including any monies owed in a repayment plan?

Yes

Have you been convicted of a felony?

No

Yes

No

If "Yes," please attach any available information.

Licensing Please list the states in which you are licensed to originate insurance policies:___________________________________________________________ __________________________________________________________________________________________________________________________ Have any of the above licenses ever been revoked or suspended by a carrier or the Department of Yes No Insurance? Did you start your business with a Rollover for Business Startups (ROBS)?

Yes

No

Is your business owned by a ROBs?

Yes

No

If "Yes," please attach details.

Required Loan Information Please provide a DETAILED EXPLANATION for the use of the loan proceeds (be specific):

General Certifications The undersigned hereby: 1)

certifies that the statements set forth in this application and attachments are true;

2)

authorizes Oak Street to investigate business, personal and/or criminal history of principal(s), financial and credit records, including investigation by credit reporting agencies of its choice before and after the extension of any credit:

3)

authorizes Oak Street to check employment history and to answer questions about its credit expierence with me;

4)

Authorizes Oak Street to have third parties assist in and/or conduct due diligence, including without limitation, sharing and auditing of financial statements and other confidential information;

5)

certifies that the applicant is duly authorized under the laws of its State of Incorporation and is properly licensed to conduct the business of selling insurance contracts in the jurisdiction in which it does so; and

6)

understands that Oak Street will retain this application whether or not it is approved.

Authorized Signature(s):______________________________________________________ Date:__________________________ Principal/Applicant Printed Name:____________________________________ Title:__________________ SSN:____________________________ Signature:_______________________________________________________________

Date:__________________________

Principal/Co-Applicant Printed Name:_________________________________ Title:_________________

SSN:____________________________

Signature:_________________________________________________________________ Date:__________________________ IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT - To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. FEDERAL EQUAL CREDIT OPPORTUNITY ACT NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercises any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Office of the Comptroller of the Currency, Customer Assistance Group, 1301 McKinney Street, Suite 3450, Houston, TX 77010, toll-free number: 800-631-6743, fax number: 713-336-4302, TDD number: 713-658-0340. As of January, 11, 2019

2019-01-11-commercial-loan-application  
2019-01-11-commercial-loan-application