First Name is required
Last Name is required
Email Address is required
Phone # is required
Business Name is required
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Armed Forces (AP)
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Select Your State is required
Type of Agency?
Type of Agency?
Individual Broker
Agency with sub-agents
Type of Agency? is required
How many years in business?
How many years in business? is required
Website URL
Website URL is required
How many agents do you plan on bringing onboard?
How many agents do you plan on bringing onboard? is required
How many businesses do you have direct relationships with?
How many businesses do you have direct relationships with? is required
Desired launch date?
Desired launch date? is required
Please describe your business and services represented
Please describe your business and services represented is required
What are the top 3 products that you sell?
What are the top 3 products that you sell? is required
Do you have Life Insurance License?
Yes
Do you have Life Insurance License? is required
Do you have Health Insurance License?
Yes
Do you have Health Insurance License? is required
Do you have P&C Insurance License?
Yes
Do you have P&C Insurance License? is required
Individual
$ 173
Individual and Spouse
$ 273
Individual and Children
$ 323
Family
$ 353
Plan
Tier
18-29
30-49
50-64
IUA $1000
Employee Only (EE)
$ 321
$ 348
$ 433
Employee Spouse (ES)
$ 578
$ 603
$ 753
Employee Child (EC)
$ 640
$ 655
$ 805
Family
$ 805
$ 815
$ 1040
Plan
Tier
18-29
30-49
50-64
IUA $2500
Employee Only (EE)
$ 268
$ 288
$ 383
Employee Spouse (ES)
$ 473
$ 513
$ 653
Employee Child (EC)
$ 525
$ 665
$ 705
Family
$ 700
$ 710
$ 875
Plan
Tier
18-29
30-49
50-64
IUA $5000
Employee Only (EE)
$ 243
$ 268
$ 318
Employee Spouse (ES)
$ 418
$ 473
$ 568
Employee Child (EC)
$ 470
$ 525
$ 620
Family
$ 595
$ 650
$ 785
Submit
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