Agent Website Build Request Template Part 1

1
Name* This field is required.First and Last Name
First Name
Last Name
Suffix
2
Business NameExample: John Doe Insurance, LLC *** If you do not have a formal business name you can leave this blank.
3
AddressThis address will be shown on your website as your business location.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Phone Number* This field is required.You Can Use the Number from Your CRM Here
Please enter a valid phone number.
5
Select a Domain (Website Address) Format* This field is required.This will be used for your professional email address in the next question.
FirstNameLastName.com
FirstNameLastNameInsurance.com
FirstName-Lastname.com
FirstNameLastNameAgent.com
I Have A Domain
6
What Do you Want The Beginning of Your Professional Email Address To Be?* This field is required.Example: info@FirstNameLastName.com
7
Do You Have a Business Facebook Page?Link to Your Facebook Page
8
Do You Have a Business LinkedIn Page?Link to Your LinkedIn Page
9
Do You Have an X Profile?Link to Your X Profile
10
Do You Plan on Running Facebook or Google Ads?We can add your Facebook or Google Ads tracking codes to your website to improve the performance of your campaigns.
YESNO
11
Facebook Tracking CodeDo you know your Facebook Tracking Code? If not - we can add this later or you can ask Bedrock to create more leads for you through Facebook marketing - just let us know.
Huge
Large
Normal
Small
Ok
Ok
12
Google Ads Tracking CodeDo you know your Google Ads Tracking Code? If not - we can add this later or you can ask Bedrock to create more leads for you through Google Ads marketing - just let us know.
Huge
Large
Normal
Small
Ok
Ok
13
Hours of Operation* This field is required.Example: Monday - Friday 9 - 5 and Saturdays 9 - Noon
14
NPN* This field is required.National Producer Number
15
How to Get Your Sunfire PURL LinkWatch this video to get your PURL which will be needed for the next step.
16
Enter Your Sunfire PURL LinkThis link allows people to Enroll in Medicare plans directly through your website, with you as the writing agent. *** You can get this from the Sunfire website.
17
CA License Number*** This is REQUIRED for Agents with a CA License.
18
Upload Your Logo.pdf, .jpg, .jpeg, or .png Max File Size 20MB
Drag and drop files here
Select files to upload
Max. file size: 20.0MB
Cancelof
19
I Verify That All Information Is Correct* This field is required.Sign Here to Verify
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