Health Insurance Co-Brokering Program

This program is designed for agents that come across health insurance opportunities but turn them down do to the following:

We can help you with your health insurance cases and put a little money in your pocket at the same time.  All you have to do is complete the following information, and we will do the rest.  Thank you for your business!

AGENT NAME:   PHONE:   E-MAIL:

I WOULD LIKE CONTACT WITH MY CLIENT TO BE HANDLED:

By checking this box you give Custom Insurance Marketing permission to contact your client only for the purpose of placing their health insurance case.

I want all contact to go through me.

Client Information
First Name:
Last Name:
Gender:
Date of Birth:
Height:
Weight:
Tobacco User:
Student:  YES   NO
Phone:
E-mail:
Address:
City:
State:
Zip Code:

Spouse Information
Gender:
Date of Birth:
Height:
Weight:
Tobacco User:
Student:  YES   NO
Children Information
Child #1
Gender:
Date of Birth:
Height:
Weight:
Tobacco User:
Student:  YES   NO
Child #2
Gender:
Date of Birth:
Height:
Weight:
Tobacco User:
Student:  YES   NO
Child #3
Gender:
Date of Birth:
Height:
Weight:
Tobacco User:
Student:  YES   NO
Child #4
Gender:
Date of Birth:
Height:
Weight:
Tobacco User:
Student:  YES   NO
Child #5
Gender:
Date of Birth:
Height:
Weight:
Tobacco User:
Student:  YES   NO
Additional Comments