Agent Intake Form 2

“Join a legacy. Grow a healthy, sustainable business. Stay independent—with support.”
Let's Get Some Details
This is a REAL, new, unique opportunity to join an established growing agency and become independent. Your inquriey and or information will NOT be shared publicly.
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First NameLast Name
“Why are you considering a change?”
In what states are you P&C licensed?
Are you life licensed?
Do you have any Non‑compete / non‑solicit restrictions?
If yes to Non‑compete / non‑solicit restrictions, would you be willing to share it with us?
Can you pass a Background check? (criminal, regulatory, financial red flags)
Have you had any Carrier or Agency terminations?
What types of clients do you focus on?
What hurdle(s) are you currently experiencing that have you exploring options?
What support do you expect from an agency?
Would you be willing to sign a "Non-Disclosure Agreement" to continue discussions with details?
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“Join a legacy. Grow a healthy, sustainable business. Stay independent—with support.”