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Agent/Agency Name:                    

Agency Address:                    Suite #        

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Address to Send Commission Checks:                     Suite #        

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Fax:     (example: 555-555-5555)

 

LEAD INFORMATION

 

Business Name:      

 

Contact Name:    

                                                                                                                                                              

Address:                     Suite #        

City:         State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Montana Maryland Massachusetts Minnesota Mississippi Missouri Nebraska New Jersey New Hampshire New Mexico New York Nevada North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming     Zip: 

Phone:              Email:        

           (example: 555-555-5555)                                    (example: suesmith@GFInetwork.com)                     

Fax:   (example: 555-555-5555)

 

Line of Business:    

 

 

 

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Date received by GFI:     Spoke To:

                                  example: (01-01-2007)

 

1st Contact with Client:         Date Submitted to Carrier:                       

                                                                                

 

 Date Received Quote from Carrier:          Date Presented to insured:  

 

                   

                                                                            Accepted     Declined                                                                                                                                                      

 

Additional Information Requested:                                            Comments:            

   

               

 

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