Notification of Link Sent

1
Agent's Name* This field is required.Please enter the first and last name of the agent you are contracting.
First Name
Last Name
2
Carrier Name* This field is required.Please enter the name of the carrier that you sent a contracting link for to your agent.
3
Contract Sent Date* This field is required.Please select the date that the contracting link was sent to the agent.
Date
Year
Month
Day
4
Agent's Level* This field is required.Please use the drop-down menu to identify the level your agent will be at.
Agent
Solicitor (LOA)
GA
MGA
5
Agent's Compensation* This field is required.Please use the drop-down menu to identify whether the agent is Direct or Indirect.
Direct Pay-Agent will receive commission payments directly from the carrier.
Indirect Pay- Agent will assign commissions to their immediate upline.
6
Agent's Hierarchy* This field is required.Please complete the full hierarchy for this agent. Do not leave any blanks. Enter N/A for any levels that do not apply.
SGA
MGA
GA
7
Agent's Email Address* This field is required.Please enter the email address for the agent you are contracting.
example@example.com
8
Agent's SSN* This field is required.Please enter the full social security number for the agent you are contracting. (Numeric entry only, do not use the dashes)
9
Agent's NPN* This field is required.Please enter the National Producer Number for the agent you are contracting.
10
Agent's Birthday* This field is required.Please enter the Date of Birth for the agent you are contracting.
Date
Year
Month
Day
Should be Empty: