AUI Client Insurance Referral Agreement Application

Insurance Client Referral Application

Insurance Business Referral Agent Application

Please note: This is intended for 1099 contractors or business insurance entrepreneurs.

Company or Business Name

First Name

Last Name

Telephone Number

Website URL

Do you have someone in your office that will call the customer back on there appointment schedule time to give them a quote?

How many years have you been in business?

Are you able to guarantee the customer the lowest rate with the best insurance coverages?

What insurance providers do you use to write polices?

PLEASE NOTE: You will only be billed once we send you a prospective insurance referral to quote.

Billing Address - must match the credit card on file.

Address Line 1

Address Line 2

City

State

Zip Code

Country

Credit card number

Expiration Date

CVV Code

I consent to have this website store my submitted information so they can respond to my inquiry. FEE SCHEDULES FOR PAYMENTS OPTION I. Pay-As-You-Go: A valid credit will need to be kept on file for billing purposes only for any leads distributed to you in real-time. I am authorized to be billed for the AUI customer referral lead for $25.00 per lead to receiving a home, automobile, life, or health insurance quote that is sent to me via email. For all commercial lead quotes, the fee is $50.00 which is sent via email. PAYMENTS PER LEAD AND INSURANCE POLICIES WRITTEN OPTION II. For any signed policy agreement between your company and our AUI referral customer, we will charge a 5%-8% or a flat rate of the amount of the total insurance premium policy written. This will apply to all renewals. We will discuss with you personally the rate that is to be determined.

Affordable USA Insurance

Phone Number

Contact Address

Email Address

Insurance Business Referral Agent Application

PLEASE NOTE: You will only be billed once we send you a prospective insurance referral to quote.

Contractors

Award

Customers