Agent/Agency Contact Information |
| Agency Name: | |
| Agency Type: | Independent Agency Exclusive Agency
|
| Your First Name: |
|
| Your Last Name: |
|
| Your Contact Email: |
|
| Choose a User Name: |
|
| Choose a Password: |
|
| Street Address: |
|
| City: |
|
| State |
|
| Zipcode: | |
| Phone: |
|
| Secondary Phone: |
|
| Agency/Agent Photo (optional): |
|
Legal License Information |
| Please provide your individual producer license number. We will verify this license information through NIPR’s Producer Database and/or any applicable state’s insurance department prior to your participation. |
| State License: | |
| License Number: |
|
Leads |
| Please select What type of leads would you like: |
|
|
|
States of Interest |
| Select the states for which you wish to purchase leads: |
|
|
Please read before submitting this form |
Under the Federal Electronic Signatures in Global and National Commerce Act, before Allinsurancemall.com may accept your account agreement and related information electronically, we must provide you with certain of the following information and you must affirmatively agree to the following and thereafter not withdraw your agreement.
Please take a moment to review and acknowledge your understanding and acceptance of this Agreement. Once you click the SUBMIT button you are indeed comfirming that you agree with all of our terms and conditions.
By agreeing below and submitting it this form via the internet, I acknowledge that:
- I have read and understood the foregoing Electronic Agreement, and that I intend to rely upon it and understand that Allinsurancemall.com will rely upon it, and that I intend to be bound thereby.
- I understand and agree that my electronic signature is the equivalent of a manual signature and that Allinsurancemall.com may rely on it as such in connection with any and all agreements I may enter into with Allinsurancemall.com including but not limited to this Electronic Signature Agreement.
- I further acknowledge and agree that it is my obligation to immediately advise Allinsurancemall.com of any change in my electronic address (i.e., email address).
- I further acknowledge and agree that it is my obligation to immediately advise Allinsurancemall.com in the event that I withdraw my consent to this Electronic Agreement.
- I acknowledge and agree that in the event that any person known to me (whether it be a family member, member of my household or otherwise) misappropriates any of the internet capable devices connected with my Allinsurancemall.com account application and such misappropriation could not reasonably be detected by Allinsurancemall.com, Allinsurancemall.com shall have the right to treat all resulting electronic usage as though they were affixed by the person whose name appears above on this form.
- I acknowledge and agree that the individual completing this electronic account application is the individual in whose name the account is being requested.
Our terms and conditions can be read here
|
| Please enter the string shown in the image in the form |
|
| |
