MANAGER/PRODUCER QUESTIONNAIRE
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Please select appropriate statement.
*
Please Select
I am looking for new affilation
I am looking for new market
I am looking for new product
I am looking to replace a product and company
I am shopping
What kind of insurance do you sell? (check all that apply)
*
Individual Health
Term
Annuities
Group Health
UL or Whole Life
Individual Retirement
Other
What is your market? (check all that apply)
*
Self Employeed
Senior
Individual
Special Markets
Other
What companies do you represent?
How many years have you been selling insurance?
In what states are you licensed?
Are you a manager or own your own agency?
Yes
No
How many agents work for you?
Do you personally write business?
Are you a broker?
Submit
Should be Empty: