Quote Just 4 U.com - Agent Enrollment Form

B e n e f i t s

Becoming a Quote Just 4 U.com agent will open the door to more opportunities for both you and your clients. Only our trusted agents will have a reserved place on the list of insurance companies which we refer to when clients request an insurance quote. Thus, this generates more customers for you and makes the customer happy as well.

C o s t

Wise Q Say: Nothing worth value in this world ever available for no value. To become an agent you must sacrifice the following:

$50 for the semi-annual (every six months) membership fee
$8 for each individual insurance lead
$10 for a group or business insurance lead

ALL LEADS are EXCLUSIVE to one agent only.

S i g n U p

To become a qualified agent you must also be a well trusted and professional insurance provider. If you fill these shoes, simply fill out the forms below and the master will be with you shortly.

First Name	*
Last Name	*
Agency	*
Website URL
E-mail
Phone	( ) *
Fax	( )
Address	*
City	*
State	*
Zip Code	*

# Of Leads Requested Per Month
*

What Type Of Insurance Product Do You Provide?
*

* indicates a required field.

Comments? Suggestions?

(NOTICE: This form e-mails the president of Quote Just 4 U.com. Read our privacy policy for more on how we handle your personal information.)

Click here for the easiest, most painless quotes on the net!

A G E N T S O N L Y

Join today! Become one of our many agents to provide consumers with quick and efficient insurance coverage.

Discover who we are and find everything from our vision statement to company policy.

a l l y o u r i n s u r a n c e a r e b e l o n g t o u s
site design and content © 2001 Quote Just 4 U.com
inquiring minds may be interested in our privacy policy.