ISM - Comprehensive-Advanced-High Commission

COMPREHENSIVE - ADVANCED - HIGH COMMISSIONS

Thank you for your interest in letting us help you grow your business. Getting contracted with us is an easy and painless process. Before you can begin marketing and selling our products in the marketplace you must be contracted with us and the insurance carrier. If you are a licensed agent, you can start the process by filling out and submitting the questionnaire below and an ISM team member will contact you shortly.

Name *

Street *

City/State/Zip *

Office Phone *

Mobile Phone *

Email *

example@example.com

I am:

Looking for a new affiliation Looking for a new market Looking for a new product

What kind of products do you currently sell?

Term Life UL or Whole Life Annuities Individual Retirement Group Health Individual Health Other

What is your market?

Self-employed Online Applications Individual Senior

Companies appointed with

Years selling insurance

In which states are you licensed?

Are you a manager?

Yes No

If yes, how many agents?

Do you own your own agency?

Yes No

If yes, how many agents?

Yes No

If yes, how many agents?

Do you own your own agency?

Yes No

Do you personally write business through an agency?

Yes No

Are you a broker?

Yes No

ISM is committed to protecting and respecting your privacy. and we'll only use your personal information to administer your account and to provide the services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you If you consent to us contacting you for this purpose.

I agree to receive other communications from Interstate Specialty Marketing Inc. ISM may contact me via email, telephone or postal mail, If the phone number have provided is a mobile phone number, agree that ISM may contact me via text message or voice.

Youmay unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committedto protecting and respecting your privacy, please review our Privacy Policles

By submitting this form, you consent to allow ISM to store and process the personal information submitted above to provide you the content requested