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Below is the enrollment form which must be filled out to become active in our pay per exclusive lead program. Upon completion, you will receive leads from your selected territory (if available) immediately. After a visitor from your selected territory completes a quote request, that lead will be sent to your e-mail. You can limit how many leads you want per week. You will be charged at the completion of the week. For a short period of time, the setup fee of $500 is waived. The per lead (exclusive) rate is $10 at this time.

Fields in red are required

Contact information
 
Agency Name:
Contact Name:
Cell Phone Number: ( )
Cell Phone Provider (ex: T-Mobile):
Fax Number:
E-mail Address:
Address:
 
City:
State:
[Credit Card Billing] Zip Code:
 

Licensing Information:


Please list the States in which you are licensed along with the type of license and the license number(s) for the State(s).

Agent Services: Leads


LINE OF BUSINESS SELECTION (required)

Click on the select box for the type of leads that you wish to receive for each of the zip codes that you enter below.

You must choose at least one line of coverage and a minimum of 15 zip codes.

Auto
Property
Business (P & C)
Life
Long Term Care
Health - Individual/Family Plan
Health - Small Group


ZIP CODE SELECTION (Required. You must select at least 15 zip codes.)

Please type the zip codes that you would like to reserve in the boxes below. This page allows you to select your first 30 zip codes. If you would like a larger number of zip codes (for example: a County, Area Code, or State) please make a note in the comment box below. Include the territory that you would like, along with the lines of business.

This will assist you in making your selection.

Enter the zip codes you wish to reserve.

Additional Territory Request: (please add any additional territory requests here. For example, if you would like a larger territory than you listed above, simply list the County, area code, or State that you would like to reserve and we will take care of the rest. You can even give us a radius (in miles) around a zip code and we will insert all zip codes within the number of miles you request.)


COMPANY SELECTION (at least one is required)

Please select your top 5 insurance carriers. (The order is not important). You must choose at least one company from the list.







CREDIT CARD ENTRY (required)

Please enter your credit card information to complete your membership. This is a secure page.

Please note:

  • You will not be charged for any setup fee.
  • There are no monthly fees, or maintenance fees.
  • Your credit information is kept offline in our transaction system (it is not in an online database).
  • You will receive an e-mail invoice at the end of each week.
  • We will charge your credit card weekly equal to the balance minus any credit.
Credit card type Visa  Mastercard 
American Express  Discover 
Expiration date
Name on card
Credit Card Number
Please note: We do not database your credit card number, your credit information is kept offline in our transaction system. If you have any questions, or concerns, regarding the security of the payment process please contact Leads
CVV
(Visa and Mastercard)

(Your credit card has a 3-digit security code found on the back of your card, listed after your credit card number in the signature area. We request you enter this number as an added security measure.)

By submitting your information to quickhealthinsurance.com, you agree to the above terms along with the quickhealthinsurance.com TERMS OF SERVICE as outlined HERE

IN ORDER TO CONTINUE, YOU MUST AGREE TO THE TERMS OF SERVICE as outlined HERE BY TYPING
"I agree" in the following box:

AGREEMENT:
Please list any additional comments:

 

 

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