Registration Form

1
Name* This field is required.
First Name
Last Name
2
Best Phone Number for clients to reach you* This field is required.
Area Code
Phone Number
3
Email* This field is required.
example@example.com
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How did you hear about us?* This field is required.
Social Media
Word Of Mouth
Email
Refer
5
ReferenceIf Any
Ex. Name Of Reffered Person
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How many workable leads do you have for our team to call?* This field is required.Unresolved leads or bad phone numbers are not considered workable
Please Select
Please Select
Less Than 100
100-150
150-200
200+
7
Service Level* This field is required.
Please Select
Please Select
Bronze 4-5
Silver 8-10
Gold 16-20
Platnium
8
Lead Type* This field is required.Best Results = <90 Days or Newer Leads
Policy Owner
PLUS (Referrals Boost)
Veterans (Rrsponse Cards)
Will Kits
Unions
Credit Union
Globe Life
9
Field Days* This field is required.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
10
Any schedule exceptions* This field is required.Only full time schedules may be considered for service; less than 40 hours per week is ineligible
Ex. Personal Appointments etc.
11
Start Date & Time* This field is required.Only full time schedules may be considered for service; less than 40 hours per week is ineligible
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Year
Month
Day
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Minutes
AM
AM
PM
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First Appt Time* This field is required.Only full time schedules may be considered for service; less than 40 hours per week is ineligible
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Last Appt Time* This field is required.Only full time schedules may be considered for service; less than 40 hours per week is ineligible
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Comments
Huge
Large
Normal
Small
Ok
Ok
15
What US states will you need us to call for?* This field is required.If using a desktop, please hold CTRL / Command when selecting multiple territories
Please Select
Please Select
ALL
NONE
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
16
What CAN provinces will you need us to call for?* This field is required.If using a desktop, please hold CTRL / Command when selecting multiple territories
Please Select
Please Select
ALL
NONE
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
17
What is your local timezone?* This field is required.
18
Calendly is required, Please provide your Link* This field is required.
19
Additional Back Up Presentation Platforms* This field is required.
Google Duo / Meet
Facetime
Whatsapp
20
ID Badge* This field is required.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
21
How would you prefer we handle call backs for missed appointments/no shows?* This field is required.
Please Select
Please Select
Primesetters Calls Within 24 Hours To Re-schedule
Agents Calls Themselves
Should be Empty: