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affordableusainsurance.com Open in urlscan Pro
35.208.243.101  Public Scan

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URL: https://affordableusainsurance.com/aui-client-insurance-referral-agreement-application/
Submission: On September 20 via manual from AU — Scanned from AU

Form analysis 4 forms found in the DOM

POST 

<form data-form_id="4" id="fluentform_4" class="frm-fluent-form fluent_form_4 ff-el-form-top ff_form_instance_4_1 ff-form-loaded" data-form_instance="ff_form_instance_4_1" method="POST">
  <p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_1" name="ak_js" value="1663640359809"></p><input type="hidden"
    name="__fluent_form_embded_post_id" value="256"><input type="hidden" id="_fluentform_4_fluentformnonce" name="_fluentform_4_fluentformnonce" value="4a0d0aa9c7"><input type="hidden" name="_wp_http_referer"
    value="/aui-client-insurance-referral-agreement-application/">
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_input_text_2">Company Name</label> </div>
    <div class="ff-el-input--content"><input type="text" name="input_text_2" class="ff-el-form-control" data-name="input_text_2" id="ff_4_input_text_2"></div>
  </div>
  <div data-type="name-element" data-name="names" class=" ff-field_container ff-name-field-wrapper">
    <div class="ff-t-container">
      <div class="ff-t-cell ">
        <div class="ff-el-group  ff-el-form-top">
          <div class="ff-el-input--label asterisk-right"><label for="ff_4_names_first_name_">First Name</label> </div>
          <div class="ff-el-input--content"><input type="text" name="names[first_name]" id="ff_4_names_first_name_" class="ff-el-form-control" placeholder="First Name"></div>
        </div>
      </div>
      <div class="ff-t-cell ">
        <div class="ff-el-group  ff-el-form-top">
          <div class="ff-el-input--label asterisk-right"><label for="ff_4_names_last_name_">Last Name</label> </div>
          <div class="ff-el-input--content"><input type="text" name="names[last_name]" id="ff_4_names_last_name_" class="ff-el-form-control" placeholder="Last Name"></div>
        </div>
      </div>
    </div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_email">Email</label> </div>
    <div class="ff-el-input--content"><input type="email" name="email" id="ff_4_email" class="ff-el-form-control" placeholder="Email Address" data-name="email"></div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_input_text">Telephone Number</label> </div>
    <div class="ff-el-input--content"><input type="text" name="input_text" class="ff-el-form-control" data-name="input_text" id="ff_4_input_text"></div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_url">Website URL</label> </div>
    <div class="ff-el-input--content"><input type="url" name="url" class="ff-el-form-control" data-name="url" id="ff_4_url"></div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_dropdown">Do you have someone in your office that will call the customer back on there appointment schedule time to give them a quote?</label> </div>
    <div class="ff-el-input--content"><select name="dropdown" id="ff_4_dropdown" class="ff-el-form-control" data-name="dropdown" data-calc_value="0">
        <option value="">- Select -</option>
        <option value="Yes">Yes</option>
        <option value="No">No</option>
        <option value="Slight Delay">Slight Delay</option>
      </select></div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_input_text_1">How many years have you been in business?</label> </div>
    <div class="ff-el-input--content"><input type="text" name="input_text_1" class="ff-el-form-control" data-name="input_text_1" id="ff_4_input_text_1"></div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_dropdown_1">Are you able to guarantee the customer the lowest rate with the best insurance coverages?</label> </div>
    <div class="ff-el-input--content"><select name="dropdown_1" id="ff_4_dropdown_1" class="ff-el-form-control" data-name="dropdown_1" data-calc_value="0">
        <option value="">- Select -</option>
        <option value="Yes">Yes</option>
        <option value="No">No</option>
        <option value="Most likely">Most likely</option>
      </select></div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_input_text_3">What insurance providers do you use to write polices?</label> </div>
    <div class="ff-el-input--content"><input type="text" name="input_text_3" class="ff-el-form-control" data-name="input_text_3" id="ff_4_input_text_3"></div>
  </div>
  <div class="ff-name-address-wrapper fluent-address" data-type="address-element" data-name="address_1">
    <div class="ff-el-input--label"><label>Billing Address - must match the credit card on file.</label></div>
    <div class="ff-el-input--content">
      <div class="ff-t-container">
        <div class="ff-t-cell">
          <div class="ff-el-group">
            <div class="ff-el-input--label asterisk-right"><label for="ff_4_address_1_address_line_1_">Address Line 1</label> </div>
            <div class="ff-el-input--content"><input type="text" name="address_1[address_line_1]" id="ff_4_address_1_address_line_1_" class="ff-el-form-control" placeholder="Address Line 1" data-key_name="address_line_1"></div>
          </div>
        </div>
        <div class="ff-t-cell">
          <div class="ff-el-group">
            <div class="ff-el-input--label asterisk-right"><label for="ff_4_address_1_address_line_2_">Address Line 2</label> </div>
            <div class="ff-el-input--content"><input type="text" name="address_1[address_line_2]" id="ff_4_address_1_address_line_2_" class="ff-el-form-control" placeholder="Address Line 2" data-key_name="address_line_2"></div>
          </div>
        </div>
      </div>
      <div class="ff-t-container">
        <div class="ff-t-cell">
          <div class="ff-el-group">
            <div class="ff-el-input--label asterisk-right"><label for="ff_4_address_1_city_">City</label> </div>
            <div class="ff-el-input--content"><input type="text" name="address_1[city]" id="ff_4_address_1_city_" class="ff-el-form-control" placeholder="City" data-key_name="city"></div>
          </div>
        </div>
        <div class="ff-t-cell">
          <div class="ff-el-group">
            <div class="ff-el-input--label asterisk-right"><label for="ff_4_address_1_state_">State</label> </div>
            <div class="ff-el-input--content"><input type="text" name="address_1[state]" id="ff_4_address_1_state_" class="ff-el-form-control" placeholder="State" data-key_name="state"></div>
          </div>
        </div>
      </div>
      <div class="ff-t-container">
        <div class="ff-t-cell">
          <div class="ff-el-group">
            <div class="ff-el-input--label asterisk-right"><label for="ff_4_address_1_zip_">Zip Code</label> </div>
            <div class="ff-el-input--content"><input type="text" name="address_1[zip]" id="ff_4_address_1_zip_" class="ff-el-form-control" placeholder="Zip" data-key_name="zip"></div>
          </div>
        </div>
        <div class="ff-t-cell">
          <div class="ff-el-group">
            <div class="ff-el-input--label asterisk-right"><label for="ff_4_address_1_country_">Country</label> </div>
            <div class="ff-el-input--content"><select name="address_1[country]" id="ff_4_address_1_country_" class="ff-el-form-control" placeholder="Select Country" data-key_name="country">
                <option value="">Select Country</option>
                <option value="AF">Afghanistan</option>
                <option value="AX">Aland Islands</option>
                <option value="AL">Albania</option>
                <option value="DZ">Algeria</option>
                <option value="AS">American Samoa</option>
                <option value="AD">Andorra</option>
                <option value="AO">Angola</option>
                <option value="AI">Anguilla</option>
                <option value="AQ">Antarctica</option>
                <option value="AG">Antigua and Barbuda</option>
                <option value="AR">Argentina</option>
                <option value="AM">Armenia</option>
                <option value="AW">Aruba</option>
                <option value="AU">Australia</option>
                <option value="AT">Austria</option>
                <option value="AZ">Azerbaijan</option>
                <option value="BS">Bahamas</option>
                <option value="BH">Bahrain</option>
                <option value="BD">Bangladesh</option>
                <option value="BB">Barbados</option>
                <option value="BY">Belarus</option>
                <option value="PW">Belau</option>
                <option value="BE">Belgium</option>
                <option value="BZ">Belize</option>
                <option value="BJ">Benin</option>
                <option value="BM">Bermuda</option>
                <option value="BT">Bhutan</option>
                <option value="BO">Bolivia</option>
                <option value="BQ">Bonaire, Saint Eustatius and Saba</option>
                <option value="BA">Bosnia and Herzegovina</option>
                <option value="BW">Botswana</option>
                <option value="BV">Bouvet Island</option>
                <option value="BR">Brazil</option>
                <option value="IO">British Indian Ocean Territory</option>
                <option value="VG">British Virgin Islands</option>
                <option value="BN">Brunei</option>
                <option value="BG">Bulgaria</option>
                <option value="BF">Burkina Faso</option>
                <option value="BI">Burundi</option>
                <option value="KH">Cambodia</option>
                <option value="CM">Cameroon</option>
                <option value="CA">Canada</option>
                <option value="CV">Cape Verde</option>
                <option value="KY">Cayman Islands</option>
                <option value="CF">Central African Republic</option>
                <option value="TD">Chad</option>
                <option value="CL">Chile</option>
                <option value="CN">China</option>
                <option value="CX">Christmas Island</option>
                <option value="CC">Cocos (Keeling) Islands</option>
                <option value="CO">Colombia</option>
                <option value="KM">Comoros</option>
                <option value="CG">Congo (Brazzaville)</option>
                <option value="CD">Congo (Kinshasa)</option>
                <option value="CK">Cook Islands</option>
                <option value="CR">Costa Rica</option>
                <option value="HR">Croatia</option>
                <option value="CU">Cuba</option>
                <option value="CW">Curaçao</option>
                <option value="CY">Cyprus</option>
                <option value="CZ">Czech Republic</option>
                <option value="DK">Denmark</option>
                <option value="DJ">Djibouti</option>
                <option value="DM">Dominica</option>
                <option value="DO">Dominican Republic</option>
                <option value="EC">Ecuador</option>
                <option value="EG">Egypt</option>
                <option value="SV">El Salvador</option>
                <option value="GQ">Equatorial Guinea</option>
                <option value="ER">Eritrea</option>
                <option value="EE">Estonia</option>
                <option value="ET">Ethiopia</option>
                <option value="FK">Falkland Islands</option>
                <option value="FO">Faroe Islands</option>
                <option value="FJ">Fiji</option>
                <option value="FI">Finland</option>
                <option value="FR">France</option>
                <option value="GF">French Guiana</option>
                <option value="PF">French Polynesia</option>
                <option value="TF">French Southern Territories</option>
                <option value="GA">Gabon</option>
                <option value="GM">Gambia</option>
                <option value="GE">Georgia</option>
                <option value="DE">Germany</option>
                <option value="GH">Ghana</option>
                <option value="GI">Gibraltar</option>
                <option value="GR">Greece</option>
                <option value="GL">Greenland</option>
                <option value="GD">Grenada</option>
                <option value="GP">Guadeloupe</option>
                <option value="GU">Guam</option>
                <option value="GT">Guatemala</option>
                <option value="GG">Guernsey</option>
                <option value="GN">Guinea</option>
                <option value="GW">Guinea-Bissau</option>
                <option value="GY">Guyana</option>
                <option value="HT">Haiti</option>
                <option value="HM">Heard Island and McDonald Islands</option>
                <option value="HN">Honduras</option>
                <option value="HK">Hong Kong</option>
                <option value="HU">Hungary</option>
                <option value="IS">Iceland</option>
                <option value="IN">India</option>
                <option value="ID">Indonesia</option>
                <option value="IR">Iran</option>
                <option value="IQ">Iraq</option>
                <option value="IE">Ireland</option>
                <option value="IM">Isle of Man</option>
                <option value="IL">Israel</option>
                <option value="IT">Italy</option>
                <option value="CI">Ivory Coast</option>
                <option value="JM">Jamaica</option>
                <option value="JP">Japan</option>
                <option value="JE">Jersey</option>
                <option value="JO">Jordan</option>
                <option value="KZ">Kazakhstan</option>
                <option value="KE">Kenya</option>
                <option value="KI">Kiribati</option>
                <option value="XK">Kosovo</option>
                <option value="KW">Kuwait</option>
                <option value="KG">Kyrgyzstan</option>
                <option value="LA">Laos</option>
                <option value="LV">Latvia</option>
                <option value="LB">Lebanon</option>
                <option value="LS">Lesotho</option>
                <option value="LR">Liberia</option>
                <option value="LY">Libya</option>
                <option value="LI">Liechtenstein</option>
                <option value="LT">Lithuania</option>
                <option value="LU">Luxembourg</option>
                <option value="MO">Macao S.A.R., China</option>
                <option value="MK">Macedonia</option>
                <option value="MG">Madagascar</option>
                <option value="MW">Malawi</option>
                <option value="MY">Malaysia</option>
                <option value="MV">Maldives</option>
                <option value="ML">Mali</option>
                <option value="MT">Malta</option>
                <option value="MH">Marshall Islands</option>
                <option value="MQ">Martinique</option>
                <option value="MR">Mauritania</option>
                <option value="MU">Mauritius</option>
                <option value="YT">Mayotte</option>
                <option value="MX">Mexico</option>
                <option value="FM">Micronesia</option>
                <option value="MD">Moldova</option>
                <option value="MC">Monaco</option>
                <option value="MN">Mongolia</option>
                <option value="ME">Montenegro</option>
                <option value="MS">Montserrat</option>
                <option value="MA">Morocco</option>
                <option value="MZ">Mozambique</option>
                <option value="MM">Myanmar</option>
                <option value="NA">Namibia</option>
                <option value="NR">Nauru</option>
                <option value="NP">Nepal</option>
                <option value="NL">Netherlands</option>
                <option value="NC">New Caledonia</option>
                <option value="NZ">New Zealand</option>
                <option value="NI">Nicaragua</option>
                <option value="NE">Niger</option>
                <option value="NG">Nigeria</option>
                <option value="NU">Niue</option>
                <option value="NF">Norfolk Island</option>
                <option value="KP">North Korea</option>
                <option value="MP">Northern Mariana Islands</option>
                <option value="NO">Norway</option>
                <option value="OM">Oman</option>
                <option value="PK">Pakistan</option>
                <option value="PS">Palestinian Territory</option>
                <option value="PA">Panama</option>
                <option value="PG">Papua New Guinea</option>
                <option value="PY">Paraguay</option>
                <option value="PE">Peru</option>
                <option value="PH">Philippines</option>
                <option value="PN">Pitcairn</option>
                <option value="PL">Poland</option>
                <option value="PT">Portugal</option>
                <option value="PR">Puerto Rico</option>
                <option value="QA">Qatar</option>
                <option value="RE">Reunion</option>
                <option value="RO">Romania</option>
                <option value="RU">Russia</option>
                <option value="RW">Rwanda</option>
                <option value="ST">São Tomé and Príncipe</option>
                <option value="BL">Saint Barthélemy</option>
                <option value="SH">Saint Helena</option>
                <option value="KN">Saint Kitts and Nevis</option>
                <option value="LC">Saint Lucia</option>
                <option value="SX">Saint Martin (Dutch part)</option>
                <option value="MF">Saint Martin (French part)</option>
                <option value="PM">Saint Pierre and Miquelon</option>
                <option value="VC">Saint Vincent and the Grenadines</option>
                <option value="WS">Samoa</option>
                <option value="SM">San Marino</option>
                <option value="SA">Saudi Arabia</option>
                <option value="SN">Senegal</option>
                <option value="RS">Serbia</option>
                <option value="SC">Seychelles</option>
                <option value="SL">Sierra Leone</option>
                <option value="SG">Singapore</option>
                <option value="SK">Slovakia</option>
                <option value="SI">Slovenia</option>
                <option value="SB">Solomon Islands</option>
                <option value="SO">Somalia</option>
                <option value="ZA">South Africa</option>
                <option value="GS">South Georgia/Sandwich Islands</option>
                <option value="KR">South Korea</option>
                <option value="SS">South Sudan</option>
                <option value="ES">Spain</option>
                <option value="LK">Sri Lanka</option>
                <option value="SD">Sudan</option>
                <option value="SR">Suriname</option>
                <option value="SJ">Svalbard and Jan Mayen</option>
                <option value="SZ">Swaziland</option>
                <option value="SE">Sweden</option>
                <option value="CH">Switzerland</option>
                <option value="SY">Syria</option>
                <option value="TW">Taiwan</option>
                <option value="TJ">Tajikistan</option>
                <option value="TZ">Tanzania</option>
                <option value="TH">Thailand</option>
                <option value="TL">Timor-Leste</option>
                <option value="TG">Togo</option>
                <option value="TK">Tokelau</option>
                <option value="TO">Tonga</option>
                <option value="TT">Trinidad and Tobago</option>
                <option value="TN">Tunisia</option>
                <option value="TR">Turkey</option>
                <option value="TM">Turkmenistan</option>
                <option value="TC">Turks and Caicos Islands</option>
                <option value="TV">Tuvalu</option>
                <option value="UG">Uganda</option>
                <option value="UA">Ukraine</option>
                <option value="AE">United Arab Emirates</option>
                <option value="GB">United Kingdom (UK)</option>
                <option value="US">United States (US)</option>
                <option value="UM">United States (US) Minor Outlying Islands</option>
                <option value="VI">United States (US) Virgin Islands</option>
                <option value="UY">Uruguay</option>
                <option value="UZ">Uzbekistan</option>
                <option value="VU">Vanuatu</option>
                <option value="VA">Vatican</option>
                <option value="VE">Venezuela</option>
                <option value="VN">Vietnam</option>
                <option value="WF">Wallis and Futuna</option>
                <option value="EH">Western Sahara</option>
                <option value="YE">Yemen</option>
                <option value="ZM">Zambia</option>
                <option value="ZW">Zimbabwe</option>
              </select></div>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_input_text_4">Credit card number</label> </div>
    <div class="ff-el-input--content"><input type="text" name="input_text_4" class="ff-el-form-control" data-name="input_text_4" id="ff_4_input_text_4"></div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_input_text_5">Expiration Date</label> </div>
    <div class="ff-el-input--content"><input type="text" name="input_text_5" class="ff-el-form-control" data-name="input_text_5" id="ff_4_input_text_5"></div>
  </div>
  <div class="ff-el-group">
    <div class="ff-el-input--label ff-el-is-required asterisk-right"><label for="ff_4_input_text_6">CVV Code</label> </div>
    <div class="ff-el-input--content"><input type="text" name="input_text_6" class="ff-el-form-control" data-name="input_text_6" id="ff_4_input_text_6"></div>
  </div>
  <div class="ff-el-group    ff-el-input--content">
    <div class="ff-el-form-check ff-el-tc"><label class="ff-el-form-check-label ff_tc_label" for="gdpr-agreement_a13fa83716d68292629797486862f620"><span class="ff_tc_checkbox"><input type="checkbox" name="gdpr-agreement"
            class="ff-el-form-check-input ff_gdpr_field" data-name="gdpr-agreement" id="gdpr-agreement_a13fa83716d68292629797486862f620" value="on"></span>
        <div class="ff_t_c">I consent to have this website store my submitted information so they can respond to my inquiry. I am authorized to be billed for the AUI customer referral lead for $12.00 per lead to receive a quote. We have 2 fee
          schedules for referral payments: OPTION I. Pay As You Go: A valid credit will need to be kept on file for billing purposes only. We charge $12.00 for each AUI customer referral lead that is sent to you directly via email for insurance
          policy quotes.&nbsp; OPTION II. For any signed policy agreement between your company and our AUI referral customer, we charge initial 8% of the policy written.&nbsp; For any insurance renewals thereafter, we charge 6% of the policy written.
          PAYMENT DUE DATE All payments are paid 30 days net from the time the policy is signed by our AUI referral customer. </div>
      </label></div>
  </div>
  <div class="ff-el-group ff-text-left ff_submit_btn_wrapper"><button type="submit" class="ff-btn ff-btn-submit ff-btn-md ff_btn_style">Submit Form</button></div>
</form>

GET https://affordableusainsurance.com/

<form role="search" method="get" class="search-form" action="https://affordableusainsurance.com/">
  <label>
    <span class="screen-reader-text">Search for:</span>
    <input type="search" class="search-field" placeholder="Search …" value="" name="s">
  </label>
  <input type="submit" class="search-submit" value="Search">
</form>

GET https://affordableusainsurance.com/

<form role="search" method="get" class="search-form" action="https://affordableusainsurance.com/">
  <label>
    <span class="screen-reader-text">Search for:</span>
    <input type="search" class="search-field" placeholder="Search …" value="" name="s">
  </label>
  <input type="submit" class="search-submit" value="Search">
</form>

GET https://affordableusainsurance.com/

<form role="search" method="get" class="search-form" action="https://affordableusainsurance.com/">
  <label>
    <span class="screen-reader-text">Search for:</span>
    <input type="search" class="search-field" placeholder="Search …" value="" name="s">
  </label>
  <input type="submit" class="search-submit" value="Search">
</form>

Text Content

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 * (951) 460-0205
 * quotes@affordableusainsurance.com
 * We service all 50 states nationwide.


AFFORDABLE USA INSURANCE

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AUI CLIENT INSURANCE REFERRAL AGREEMENT APPLICATION

   
   
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 * AUI Client Insurance Referral Agreement Application

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Website URL

Do you have someone in your office that will call the customer back on there
appointment schedule time to give them a quote?
- Select -YesNoSlight Delay
How many years have you been in business?

Are you able to guarantee the customer the lowest rate with the best insurance
coverages?
- Select -YesNoMost likely
What insurance providers do you use to write polices?

Billing Address - must match the credit card on file.
Address Line 1

Address Line 2

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State

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LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth
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and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos
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(US)United States (US) Minor Outlying IslandsUnited States (US) Virgin
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SaharaYemenZambiaZimbabwe
Credit card number

Expiration Date

CVV Code

I consent to have this website store my submitted information so they can
respond to my inquiry. I am authorized to be billed for the AUI customer
referral lead for $12.00 per lead to receive a quote. We have 2 fee schedules
for referral payments: OPTION I. Pay As You Go: A valid credit will need to be
kept on file for billing purposes only. We charge $12.00 for each AUI customer
referral lead that is sent to you directly via email for insurance policy
quotes.  OPTION II. For any signed policy agreement between your company and our
AUI referral customer, we charge initial 8% of the policy written.  For any
insurance renewals thereafter, we charge 6% of the policy written. PAYMENT DUE
DATE All payments are paid 30 days net from the time the policy is signed by our
AUI referral customer.
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The majority have suffered in some form by injected humour or words.





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