Senior Marketing Specialists Lead Order Form

Senior Marketing Specialists Lead Order Form
Please fill out the next 2 fields for the specific agent receiving the leads, as the agents name & phone # will be added to the "Thank You" page.
Name of Agent*

First NameLast Name
Phone Number of Agent*
Email (we email you a Google Sheet link)*
example@example.com
Preferred Lead Area - up to a 50 mile radius*

Street Address

Street Address Line 2

CityState

Zip Code
LEADS START DATE (optional, if left blank it will start as soon as possible)

MonthDayYear
Date
Comments
Inbound Call Feature:

We add your Name and Phone # and encourage prospects to call you.

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Lead Replacement Policy:

We will credit up to 20% (per order) of purchased leads for the following reasons:
- Duplicate lead, received within the last 90 days
- Lead outside of 50 miles
- Disconnected #'s
- Over the age of 85
- Language Barrier
Please, submit any requested replacements with specific reasons to support@secureagentleads.com within 14 days of receipt. Thank you!

SMS Discounted Lead Options: "30% OFF"*

Final Expense Leads (Retail: $25)$17.00

Quantity

Medicare Leads (Retail: $25)$17.00

Quantity

Total $0.00