Premier Insurance Leads

Agent Name*

Agent Email*

Agent Number*

Text Alert Number

Preferred lead area zip code or state if statewide (multi-state please use "additional requests" section to provide your states*

If multi-state please use additional requests section of form to list states

Date leads will start/if no date is chosen leads will start immediately

Calendar link? If applicable. Leave blank otherwise

Do you agree to receive text alerts for lead delivery*

YesNo

Additional Requests

Signature*

I have read and I agree to the terms/conditions. I authorize this charge to my card. Read terms/conditions here: https://plg.digital/

ATTENTION! IMPORTANT INFORMATION. PLEASE READ

CHECK THE BOX NEXT TO THE PRODUCT

USE THE DROP DOWN MENUS TO SELECT THE QUANTITY

BOXES MUST BE CHECKED IN ORDER TO VIEW LOCAL AND STATEWIDE LEAD OPTIONS

WE ARE A PAY PER LEAD PAY AS YOU GO VENDOR. WE DO NOT SAVE CARDS ON FILE FOR FUTURE BILLING PURPOSES

ALL LEADS ARE GENERATED IN REAL TIME JUST FOR YOU. THESE ARE FRESH EXCLUSIVE LEADS

PREMIER PREMIUM FEX LEADS INCLUDE ADDITIONAL QUESTIONS

1. Current Coverage?

2. Beneficiary

3. Reason for coverage?

11 data points!

PREMIER ADVANCED FEX LEADS INCLUDE ADDITIONAL QUESTIONS

1. Current Coverage?

2. Beneficiary

3. Reason for coverage?

4. Coverage amount desired

12 data points!

MULTI-STATE

PLEASE USE THE ADDITIONAL REQUESTS SECTION TO PROVIDE YOUR STATES. 3 OR MORE STATES ARE REQUIRED TO PROCESS YOUR PURCHASE ORDER

My Products

Premier FEX-Check the box for more optionsPremium High Intent

$28.00

	Quantity	Price
Local		$28.00
Statewide		$26.00
Multi-state		$24.00

Item subtotal:$0.00

Advanced FEX-Check the box for more options Advanced High Intent

$30.00

	Quantity	Price
Local		$30.00
Statewide		$28.00
Multi-state		$26.00

Item subtotal:$0.00

Medicare T65-Check the box for more optionsT65 Medicare

$28.00

	Quantity	Price
Statewide only		$28.00
Multi-state		$26.00

Item subtotal:$0.00

Enter coupon

Total

$0.00

Payment Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration