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americanfidelity.com Open in urlscan Pro
45.60.104.124  Public Scan

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Submitted URL: https://afbrokerage.americanfidelity.com/
Effective URL: https://americanfidelity.com/support/contact-us/brokerage/
Submission: On January 06 via automatic, source certstream-suspicious — Scanned from FR

Form analysis 1 forms found in the DOM

POST /support/contact-us/brokerage/

<form action="/support/contact-us/brokerage/" enctype="multipart/form-data" method="post" novalidate="novalidate"><input name="__RequestVerificationToken" type="hidden"
    value="YUOdd7K3NwK6hxG2htI3mtYwIUtAT2lQhOOGsChYNQDKpoC4vg6S9wm47oyfyDE_By5Wp7QrYLggTeDvR2yqgoWYn0I1"><input data-val="true" data-val-required="The FormId field is required." name="FormId" type="hidden"
    value="98c82545-86b4-44ab-9131-e08cc3021253"><input name="FormName" type="hidden" value="Broker"><input data-val="true" data-val-required="The RecordId field is required." name="RecordId" type="hidden"
    value="00000000-0000-0000-0000-000000000000"><input name="PreviousClicked" type="hidden" value=""><input name="Theme" type="hidden" value="af-contact-form"> <input type="hidden" name="FormStep" value="0">
  <input type="hidden" name="RecordState"
    value="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">
  <style>
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      width: auto !important;
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      color: var(--red3);
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    .required-wrapper p {
      position: absolute;
      text-align: right;
      margin-right: 1rem;
      right: 30px;
      width: 150px;
      width: max-content;
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    input {
      width: 95%;
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    .umbraco-forms-page .umbraco-forms-field-wrapper input[type=text],
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      margin-left: unset;
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  <div class="card col-xs-12 col-12 mx-auto ">
    <div id="FormBar" class="form-bar" style="background-color: rgb(21, 120, 133);">&nbsp;</div>
    <div class="umbraco-forms-page form-horizontal card-body px-0">
      <div class="row">
        <div class="col mb-3">
          <p><span class="umbracoForms-Indicator">*</span> Required fields </p>
        </div>
      </div>
      <fieldset class="umbraco-forms-fieldset" id="aa3bde60-44e5-46bd-bd87-c8e9cd269402" style="display: none;">
        <div class="umbraco-forms-container">
          <div class="form-group umbraco-forms-field intro titleanddescription">
            <div class="umbraco-forms-field-wrapper row">
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                  <p></p>
                  <div class="w-100 mx-auto mt-2">
                    <p>If you're already a broker partner and need assistance with sales materials, brochures, enrollment setup, and more, please
                      <a href="https://americanfidelity.com/support/contact-us/brokerage/" aria-label="Careers">visit our Broker Support page</a>. To become an Insurance Broker with American Fidelity, fill out the information below.</p>
                  </div>
                  <p></p>
                </div>
              </div>
            </div>
          </div>
        </div>
      </fieldset>
      <fieldset class="umbraco-forms-fieldset" id="557ba250-b6ee-482f-ab60-f234c2890585">
        <legend>Contact Information </legend>
        <div class="umbraco-forms-container">
          <div class="form-group umbraco-forms-field formname hidden alternating">
            <div class="umbraco-forms-field-wrapper row">
              <div class="col-12">
                <input type="hidden" name="0cf09407-3d40-443d-9d77-45dc97784861" id="0cf09407-3d40-443d-9d77-45dc97784861" data-umb="0cf09407-3d40-443d-9d77-45dc97784861" class="hidden" value="Broker Contact Form">
                <p aria-label="Invalid contents" class="d-block pl-2"><span class="field-validation-valid" data-valmsg-for="0cf09407-3d40-443d-9d77-45dc97784861" data-valmsg-replace="true"></span></p>
              </div>
            </div>
          </div>
          <div class="form-group umbraco-forms-field audiencetype hidden">
            <div class="umbraco-forms-field-wrapper row">
              <div class="col-12">
                <input type="hidden" name="46988054-0bd2-48b4-8693-794b26c034bc" id="46988054-0bd2-48b4-8693-794b26c034bc" data-umb="46988054-0bd2-48b4-8693-794b26c034bc" class="hidden" value="Broker">
                <p aria-label="Invalid contents" class="d-block pl-2"><span class="field-validation-valid" data-valmsg-for="46988054-0bd2-48b4-8693-794b26c034bc" data-valmsg-replace="true"></span></p>
              </div>
            </div>
          </div>
          <div class="form-group umbraco-forms-field firstname shortanswer mandatory alternating">
            <div class="row">
              <div class="control-label umbraco-forms-label col-12">
                <div tabindex="-1" class="control-label umbraco-forms-label col-12 p-0 mb-0">
                  <label for="e83503aa-7944-4369-b7d9-a2139c6001d6"> First Name <span class="umbracoForms-Indicator">*</span>
                  </label>
                </div>
              </div>
            </div>
            <div class="umbraco-forms-field-wrapper row">
              <div class="col-12">
                <input type="text" name="e83503aa-7944-4369-b7d9-a2139c6001d6" id="e83503aa-7944-4369-b7d9-a2139c6001d6" data-umb="e83503aa-7944-4369-b7d9-a2139c6001d6" class="text form-control" value="" maxlength="255" data-val="true"
                  data-val-required="&quot;First Name&quot; is required">
                <p aria-label="Invalid contents" class="d-block pl-2"><span class="field-validation-valid" data-valmsg-for="e83503aa-7944-4369-b7d9-a2139c6001d6" data-valmsg-replace="true"></span></p>
              </div>
            </div>
          </div>
          <div class="form-group umbraco-forms-field lastname shortanswer mandatory">
            <div class="row">
              <div class="control-label umbraco-forms-label col-12">
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                  <label for="323dde87-3310-43ed-b98b-fa2d513bd3d6"> Last Name <span class="umbracoForms-Indicator">*</span>
                  </label>
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            <div class="umbraco-forms-field-wrapper row">
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                  data-val-required="&quot;Last Name&quot; is required">
                <p aria-label="Invalid contents" class="d-block pl-2"><span class="field-validation-valid" data-valmsg-for="323dde87-3310-43ed-b98b-fa2d513bd3d6" data-valmsg-replace="true"></span></p>
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                <div tabindex="-1" class="control-label umbraco-forms-label col-12 p-0 mb-0">
                  <label for="84476071-8d81-4c64-9390-1a845f0e317c"> Email <span class="umbracoForms-Indicator">*</span>
                  </label>
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              </div>
            </div>
            <div class="umbraco-forms-field-wrapper row">
              <div class="col-12">
                <input type="text" name="84476071-8d81-4c64-9390-1a845f0e317c" id="84476071-8d81-4c64-9390-1a845f0e317c" data-umb="84476071-8d81-4c64-9390-1a845f0e317c" class="text form-control" value="" maxlength="255" data-val="true"
                  data-val-required="&quot;Email&quot; is required" data-val-regex="The value you provided is not valid for this field." data-val-regex-pattern="[a-zA-Z0-9_.+-]+@[a-zA-Z0-9-]+.[a-zA-Z0-9-.]+">
                <p aria-label="Invalid contents" class="d-block pl-2"><span class="field-validation-valid" data-valmsg-for="84476071-8d81-4c64-9390-1a845f0e317c" data-valmsg-replace="true"></span></p>
              </div>
            </div>
          </div>
          <div class="form-group umbraco-forms-field phone shortanswer">
            <div class="row">
              <div class="control-label umbraco-forms-label col-12">
                <div tabindex="-1" class="control-label umbraco-forms-label col-12 p-0 mb-0">
                  <label for="5b865a62-2f9d-4df1-928b-f8a938a2d955"> Phone </label>
                </div>
              </div>
            </div>
            <div class="umbraco-forms-field-wrapper row">
              <div class="col-12">
                <input type="text" name="5b865a62-2f9d-4df1-928b-f8a938a2d955" id="5b865a62-2f9d-4df1-928b-f8a938a2d955" data-umb="5b865a62-2f9d-4df1-928b-f8a938a2d955" class="text form-control" value="" maxlength="255">
                <p aria-label="Invalid contents" class="d-block pl-2"><span class="field-validation-valid" data-valmsg-for="5b865a62-2f9d-4df1-928b-f8a938a2d955" data-valmsg-replace="true"></span></p>
              </div>
            </div>
          </div>
        </div>
      </fieldset>
      <fieldset class="umbraco-forms-fieldset" id="df68a3e1-53fa-436f-d14d-a55683898aac">
        <legend> How would you prefer we contact you? <span aria-label="Required Field Indicator" class="umbracoForms-Indicator">*</span>
        </legend>
        <div class="umbraco-forms-container">
          <div class="form-group umbraco-forms-field howwouldyoupreferwecontactyou singlechoice mandatory alternating">
            <div class="row">
              <div class="control-label umbraco-forms-label col-12">
              </div>
            </div>
            <div class="umbraco-forms-field-wrapper row">
              <div class="col-12">
                <div class="form-control radiobuttonlist row" id="c5f9bd98-d0f1-430c-9793-293884961bf0" data-umb="c5f9bd98-d0f1-430c-9793-293884961bf0">
                  <div class="col-sm-12 col-md-5">
                    <input type="radio" data-umb="c5f9bd98-d0f1-430c-9793-293884961bf0_0" class="mrs-radio" style="margin-left: .1em;" name="c5f9bd98-d0f1-430c-9793-293884961bf0" id="c5f9bd98-d0f1-430c-9793-293884961bf0_0" value="Email"
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                    <label for="c5f9bd98-d0f1-430c-9793-293884961bf0_0" id="Label_c5f9bd98-d0f1-430c-9793-293884961bf0" class="mrs-radio-label"> Email </label>
                  </div>
                  <div class="col-sm-12 col-md-5">
                    <input type="radio" data-umb="c5f9bd98-d0f1-430c-9793-293884961bf0_1" class="mrs-radio" style="margin-left: .1em;" name="c5f9bd98-d0f1-430c-9793-293884961bf0" id="c5f9bd98-d0f1-430c-9793-293884961bf0_1" value="Phone"
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                    <label for="c5f9bd98-d0f1-430c-9793-293884961bf0_1" id="Label_c5f9bd98-d0f1-430c-9793-293884961bf0" class="mrs-radio-label"> Phone </label>
                  </div>
                </div>
                <p aria-label="Invalid contents" class="d-block pl-2"><span class="field-validation-valid" data-valmsg-for="c5f9bd98-d0f1-430c-9793-293884961bf0" data-valmsg-replace="true"></span></p>
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            </div>
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        <legend>Additional Information </legend>
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          <div class="form-group umbraco-forms-field pleaseexplainwhyyoureinterestedinbecomingabrokerpartner longanswer">
            <div class="row">
              <div class="control-label umbraco-forms-label col-12">
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              </div>
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              <div class="col-12">
                <textarea class="form-control" name="63b3fb1e-876d-469b-bff9-0985fb02a0c2" id="63b3fb1e-876d-469b-bff9-0985fb02a0c2" data-umb="63b3fb1e-876d-469b-bff9-0985fb02a0c2" rows="2" cols="20"></textarea>
                <p aria-label="Invalid contents" class="d-block pl-2"><span class="field-validation-valid" data-valmsg-for="63b3fb1e-876d-469b-bff9-0985fb02a0c2" data-valmsg-replace="true"></span></p>
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CONTACT THE BROKERAGE TEAM

 

To become an Insurance Broker with American Fidelity, fill out the information
below.

 

* Required fields

If you're already a broker partner and need assistance with sales materials,
brochures, enrollment setup, and more, please visit our Broker Support page. To
become an Insurance Broker with American Fidelity, fill out the information
below.



Contact Information

First Name *



Last Name *



Email *



Phone



How would you prefer we contact you? *
Email
Phone



Additional Information
Please explain why you're interested in becoming a broker partner. Please do not
enter any sensitive personal information.





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