www.mt-ins.com
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Submitted URL: https://www.mt-ins.com/uirForms/commons/C/?eid=58802342821&id=6887&qid=1
Effective URL: https://www.mt-ins.com/uirForms/UIRProc/index_new.php?id=6887&eid=58802342821&qid=1
Submission: On February 16 via api from IE — Scanned from DE
Effective URL: https://www.mt-ins.com/uirForms/UIRProc/index_new.php?id=6887&eid=58802342821&qid=1
Submission: On February 16 via api from IE — Scanned from DE
Form analysis 1 forms found in the DOM
POST WebForm_Proc_B.php
<form action="WebForm_Proc_B.php" method="post" enctype="application/x-www-form-urlencoded" id="frmMain" class="form" onsubmit="return verifyOnSubmit()">
<input type="hidden" id="CampaignID" name="CampaignID" value="6887">
<input type="hidden" id="queryid" name="queryid" value="1">
<input type="hidden" id="Leadsid" name="Leadsid" value="58802342821">
<input type="hidden" id="email" name="email" value="mberndt@onesharehealth.com">
<input type="hidden" id="CampaignType" name="CampaignType" value="1">
<input type="hidden" id="UpdatedEmail" name="UpdatedEmail" value="0">
<input type="hidden" id="gender" name="gender" value="">
<input type="hidden" id="businessName" name="businessName" value="">
<input type="hidden" id="businessTitle" name="businessTitle" value="">
<input type="hidden" id="businessAddress1" name="businessAddress1" value="">
<input type="hidden" id="businessAddress2" name="businessAddress2" value="">
<input type="hidden" id="businessCity" name="businessCity" value="">
<input type="hidden" id="businessState" name="businessState" value="">
<input type="hidden" id="businessZip" name="businessZip" value="">
<input type="hidden" id="homeAddress1" name="homeAddress1" value="">
<input type="hidden" id="homeAddress2" name="homeAddress2" value="">
<input type="hidden" id="homeCity" name="homeCity" value="">
<input type="hidden" id="homeState" name="homeState" value="">
<input type="hidden" id="homeZip" name="homeZip" value="">
<input type="hidden" id="homeEmail" name="homeEmail" value="">
<input type="hidden" id="currentCarrierContracts" name="currentCarrierContracts" value="">
<input type="hidden" id="businessFacebook" name="businessFacebook" value="">
<input type="hidden" id="businessTwitter" name="businessTwitter" value="">
<input type="hidden" id="businessLinkedin" name="businessLinkedin" value="">
<input type="hidden" id="personalFacebook" name="personalFacebook" value="">
<input type="hidden" id="personalTwitter" name="personalTwitter" value="">
<input type="hidden" id="personalLinkedin" name="personalLinkedin" value="">
<table id="tbl_form" border="0" width="100%" frame="void" rules="none" cellpadding="2" cellspacing="0">
<tbody>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">First Name<span style="color: red">:*</span></td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spnFirstName"><input name="firstname" type="text" tabindex="1" size="20" maxlength="30"
value="Michelle" id="firstname"></span></td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Last Name<span style="color: red">*</span></td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spnLastName"><input name="lastname" type="text" tabindex="2" size="20" maxlength="30"
value="Berndt" id="lastname"></span></td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Company<span style="color: red">*</span></td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spnAddress2"><strong><input name="company" type="text" tabindex="4" size="20" maxlength="60"
value="Best Ever"></strong></span></td>
</tr>
<!-- ********************************************************** -->
<!-- State Drop Down Control... -->
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top"> State<span style="color: red">*</span></td>
<td height="25" style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<span id="spn_State">
<select id="state" name="state" size="1" tabindex="6">
<option value="">Select State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX" selected="selected">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="PR">Puerto Rico</option>
</select>
</span>
</td>
</tr>
<!-- END State Drop Down Control... -->
<!-- ********************************************************** -->
<!-- ********************************************************** -->
<!-- The rest of the Form BEFORE the Products section ... -->
<tr id="tr_Email">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top"> Email</td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<span id="spn_Email" style="font-weight: bold; font-size: 14px; vertical-align: middle; font-family: Arial, Verdana, Sans-Serif; text-align: left"> mberndt@onesharehealth...</span>
<br>
<span id="spn_UpdateEmail" style="font-weight: bold; font-size: 10px; vertical-align: middle; font-family: Arial, Verdana, Sans-Serif; text-align: right"> (To update your email address,
<a href="/UpdP/ChangeEmailAddr.php?id=6887&eid=58802342821"><strong>CLICK HERE</strong></a>)</span>
</td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Phone<span style="color: red">*</span></td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spn_phone"><input name="phone" type="text" tabindex="9" size="20" maxlength="20"
value="817-721-2336" id="phone" onkeydown="javascript:backspacerDOWN(this,event);" onkeyup="javascript:backspacerUP(this,event);">
</span></td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Cell Phone</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spnCellPhone"><input name="cellphone" type="text" tabindex="10" size="20" maxlength="20" value=""
id="cellphone">
</span></td>
</tr>
<!-- ************************************************************************** -->
<!-- Interest Level Drop Down Control -->
<tr id="tr_InterestLevel">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">
<span style="font-family: 'Arial Narrow'; font-size: 14px">Interest Level</span><span style="color: red">*</span>
</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="interestLevel" name="interestLevel">
<option value="">--Please Select--</option>
<option value="Contact Me Now">Contact Me Now</option>
<option value="Need More Information">Need More Information</option>
<option value="Just Looking">Just Looking</option>
</select>
</td>
</tr>
<!-- ************************************************************************** -->
<!-- Custom Form Fields added April 2015 Erik Platte -->
<!-- primaryFocus was added August 2015 Erik Platte -->
<tr style="display:none;" id="tr_PrimaryFocus">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Primary Focus?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="primaryFocus" name="primaryFocus">
<option value="">--Please Select--</option>
<option value="Concept/Product">Concept/Product</option>
<option value="Selling System">Selling System</option>
<option value="Incentive">Incentive</option>
<option value="Other">Other</option>
</select>
</td>
</tr>
<tr style="display:none;" id="tr_AnnuityProduction">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">What was your Annuity Production last year?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="annuityProduction" name="annuityProduction">
<option value="">--Please Select--</option>
<option value="Under $100,000">Under $100,000</option>
<option value="Under $200,000">Under $200,000</option>
<option value="Under $500,000">Under $500,000</option>
<option value="Over $1,000,000">Over $1,000,000</option>
<option value="Over $5,000,000">Over $5,000,000</option>
</select>
</td>
</tr>
<tr style="display:none;" id="tr_LifeProduction">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">What was your Life Production last year?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="lifeProduction" name="lifeProduction">
<option value="">--Please Select--</option>
<option value="< $10,000">< $10,000</option>
<option value="$25K-$50K">$25K-$50K</option>
<option value="$50K-$100K">$50K-$100K</option>
<option value="$100K+">$100K+</option>
</select>
</td>
</tr>
<tr style="display:none;" id="tr_MedicareSupplementProduction">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">How many Medicare Supplement apps do you write per month?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<input id="medicareSupplementProduction" name="medicareSupplementProduction" type="text" size="20" maxlength="60">
</td>
</tr>
<tr style="display:none;" id="tr_VisionPoliciesPerYear">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">How many Vision policies have you sold in last 12 months?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<input id="VisionPoliciesPerYear" name="VisionPoliciesPerYear" type="text" size="20" maxlength="60">
</td>
</tr>
<tr id="tr_HowManyDentalPolicies">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">How many Dental policies have you sold in last 12 months?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<input id="HowManyDentalPolicies" name="HowManyDentalPolicies" type="text" size="20" maxlength="60">
</td>
</tr>
<tr style="display:none;" id="tr_MedicareAdvantageProduction">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">What was your Medicare Advantage Production last year?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="medicareAdvantageProduction" name="medicareAdvantageProduction">
<option value="">--Please Select--</option>
<option value="Under $10,000">Under $10,000</option>
<option value="Under $100,000">Under $100,000</option>
<option value="Under $200,000">Under $200,000</option>
<option value="Under $500,000">Under $500,000</option>
<option value="Over $1,000,000">Over $1,000,000</option>
</select>
</td>
</tr>
<tr style="display:none;" id="tr_SecurityLicense">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Which Security Licenses Do You Have?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="securityLicense" name="securityLicense[]" multiple="">
<option value="None">None</option>
<option value="Series 6">Series 6</option>
<option value="Series 7">Series 7</option>
<option value="Series 24">Series 24</option>
<option value="Series 63">Series 63</option>
<option value="Series 65">Series 65</option>
<option value="Series 66">Series 66</option>
<option value="Other">Other</option>
</select> Hold "ctrl" to make multiple selections
</td>
</tr>
<tr style="display:none;" id="tr_PrimaryProduct">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">What are the Primary Products You Sell?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="primaryProduct" name="primaryProduct[]" multiple="">
<option value="Other">Other</option>
<option value="Annuities">Annuities</option>
<option value="Securities">Securities</option>
<option value="Life">Life</option>
<option value="Health">Health</option>
<option value="Property and Casualty">Property and Casualty</option>
<option value="Dental">Dental</option>
<option value="Vision">Vision</option>
</select> Hold "ctrl" to make multiple selections
</td>
</tr>
<tr style="display:none;" id="tr_RecruitingBudget">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left;font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">What is your monthly recruiting budget?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="recruitingBudget" name="recruitingBudget">
<option value="">--Please Select--</option>
<option value="Under $1,000">Under $1,000</option>
<option value="Under $10,000">Under $10,000</option>
<option value="Under $20,000">Under $20,000</option>
<option value="Under $50,000">Under $50,000</option>
<option value="Over $100,000">Over $100,000</option>
</select>
</td>
</tr>
<tr style="display:none;" id="tr_EmailRecruiting">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Who have you used for email recruiting?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<input name="emailRecruiting" type="text" tabindex="4" size="20" maxlength="60">
</td>
</tr>
<tr style="display:none;" id="tr_AnnuityLifeSalesPlatform">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Are you currently using an online Annuity/Life sales platform?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="annuityLifeSalesPlatform" name="annuityLifeSalesPlatform">
<option value="">--Please Select--</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</td>
</tr>
<tr style="display:none;" id="tr_MajorityBusiness">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">What is the Majority of your Business?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="majorityBusiness" name="majorityBusiness">
<option value="">--Please Select--</option>
<option value="Individuals">Individuals</option>
<option value="Employers">Employers</option>
</select>
</td>
</tr>
<tr style="display:none;" id="tr_CommissionRevenue">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">What are your approximate Annual Commission Revenues?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="commissionRevenue" name="commissionRevenue">
<option value="">--Please Select--</option>
<option value="Under $500k">Under $500k</option>
<option value="$500,001 to 1M">$500,001 to 1M</option>
<option value="$1,000,001 to 5M">$1,000,001 to 5M</option>
<option value="Over $5,000,000">Over $5,000,000</option>
</select>
</td>
</tr>
<tr style="display:none;" id="tr_TypeAgency">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Describe type of Agency?</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="typeAgency" name="typeAgency[]" multiple="">
<option value="None">None</option>
<option value="PropertyCasualty">Property/Casualty</option>
<option value="LifeHealth">Life/Health</option>
<option value="Wholesaler">Wholesaler</option>
<option value="Retailer">Retailer</option>
<option value="Other">Other</option>
<option value="Series 66">Series 66</option>
<option value="Other">Other</option>
</select> Hold "ctrl" to make multiple selections
</td>
</tr>
<tr style="display:none;" id="tr_WhichSell">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top">Which do you sell:</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="whichSell" name="whichSell">
<option value="">Select</option>
<option value="Group">Group</option>
<option value="Individual">Individual</option>
<option value="Both">Both</option>
<option value="Neither">Neither</option>
</select>
</td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: 'Arial Narrow'; font-size: 14px; font-weight: bold;" valign="top"> Comments:</td>
<td style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left">
<textarea name="comment" rows="2" cols="25" id="comment"></textarea>
</td>
</tr>
<tr>
<td></td>
</tr>
<tr>
<td><input type="checkbox" name="receive_marketing" value="Yes" checked="" style="width: 2em; height: 1em;
"></td>
<td style="font-size: 10px; /*font-weight: bold;*/">By submitting this form, I agree to receive marketing materials over email, SMS and other communication channels</td>
</tr>
<tr id="tr_RowSpacer3">
<td id="td_RowCellSpacer3Left"> </td>
<td id="td_RowCellSpacer3Right" style="font-weight: normal; font-size: 14px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left"> </td>
</tr>
<tr>
<td></td>
<td> <input type="submit" id="Submit" name="Submit" value="Submit" class="btn tertiary"></td>
</tr>
</tbody>
</table>
</form>Text Content
Beat your Competition Now! These dental policies open the door to... with no extra marketing cost. You can have a reason to talk to existing clients and get referrals, Open doors for Medicare, Life, Group and Annuities. Here's a new Dental Care for All Your Clients with No Waiting Period Make it impossible for your customers to say no! Work Quickly in Less Time and Earn More Commissions! Please Complete the Form Now for More Information! * Required Fields First Name:* Last Name* Company* State* Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Email mberndt@onesharehealth... (To update your email address, CLICK HERE) Phone* Cell Phone Interest Level* --Please Select-- Contact Me Now Need More Information Just Looking Primary Focus? --Please Select-- Concept/Product Selling System Incentive Other What was your Annuity Production last year? --Please Select-- Under $100,000 Under $200,000 Under $500,000 Over $1,000,000 Over $5,000,000 What was your Life Production last year? --Please Select-- < $10,000 $25K-$50K $50K-$100K $100K+ How many Medicare Supplement apps do you write per month? How many Vision policies have you sold in last 12 months? How many Dental policies have you sold in last 12 months? What was your Medicare Advantage Production last year? --Please Select-- Under $10,000 Under $100,000 Under $200,000 Under $500,000 Over $1,000,000 Which Security Licenses Do You Have? None Series 6 Series 7 Series 24 Series 63 Series 65 Series 66 Other Hold "ctrl" to make multiple selections What are the Primary Products You Sell? Other Annuities Securities Life Health Property and Casualty Dental Vision Hold "ctrl" to make multiple selections What is your monthly recruiting budget? --Please Select-- Under $1,000 Under $10,000 Under $20,000 Under $50,000 Over $100,000 Who have you used for email recruiting? Are you currently using an online Annuity/Life sales platform? --Please Select-- Yes No What is the Majority of your Business? --Please Select-- Individuals Employers What are your approximate Annual Commission Revenues? --Please Select-- Under $500k $500,001 to 1M $1,000,001 to 5M Over $5,000,000 Describe type of Agency? None Property/Casualty Life/Health Wholesaler Retailer Other Series 66 Other Hold "ctrl" to make multiple selections Which do you sell: Select Group Individual Both Neither Comments: By submitting this form, I agree to receive marketing materials over email, SMS and other communication channels Click Here for Our Spam & Privacy Policy