Broker Intake Form
Agent Name/AD
*
Agent Name
AD Name
Agent Phone Number
*
-
Area Code
Phone Number
Agent Email
*
example@example.com
Brokers Name
*
First Name
Last Name
Brokerage Name
*
Broker Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Broker Email
*
example@example.com
Brokerage Phone #
*
Check all that apply
*
Writes P&C
Writes Commercial
Owns Agency (Ex Name on the front door)
Writes Groups
How connected? How did you meet them? Referral from friend/ Referral from Business you’ve prospected (if so, who…business name and person’s name)/Personal contact/Walk in, etc.)
*
0/25
Does the Broker service a current group that we share? If so please add the Business Name to the notes below
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YES
NO
Background Story The More Details the Better
*
Submit
Should be Empty: