Property and Casualty Form

Instructions for Submitting a Property and Casualty lead

Step 1: Fill out the form below

Step 2: Check the consent box and then select submit

Lead Info

Product interest

Auto
Homeowners
Renters
Umbrella
Other

Referral Producer Info

Do you currently hold a P&C license in the same state as the lead?

Yes

No (will receive a one time payment of $X)

Compensation Selection

I would like a one time payment of $XX

I would like to bypass the one time payment and instead I’ll split any sales between myself and the writing producer 50/50

* Missing information. Please fill out ALL fields before submitting

By submitting this form, Agent is acknowledging that they have orally received consumer’s authorization and provided oral notice that such consent is not required to make a purchase and consumer has agreed to be contacted at the phone number(s) listed, including any wireless number(s), if provided.

Submission Complete