REVOLUTION MEDIA, LLC

New Client Form

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Please Note: This form includes required fields, meaning you will not be able to click submit if any information is missing. If at any point you’d like to save your progress and return later, simply scroll to the bottom of the form and click the ‘Save and Resume Later’ link.

What is the legal name of your entity/company? *

Agent Name *

First

Last

Agent Email *

Agent Mobile Phone Number *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Upload Logo *

Drag & Drop Files, Choose Files to Upload You can upload up to 3 files.

Additional Staff

Phone number you would like listed for all marketing materials *

Email you would like listed for all marketing materials and where forms will be sent? *

What is your License number as well as the business' license number? We need all license numbers for the disclaimer that is in the footer of the website as well as any marketing material we create for you. *

Please provide any disclaimers you use. *

Please upload a copy of your department of insurance license certificate. Please note that if we do not receive this it could delay work on your project.

Drag & Drop Files, Choose Files to Upload

Do you own your URL? If so, please provide the login and password for your domain name (such as a GoDaddy Login). *

Who is your Email Provider? (For example, Gmail, Office 365, Outlook, AOL, Yahoo, etc.) *

Who are you using for Email Marketing (Mailchimp, Bomb Bomb, Constant Contact, etc)? (We are a partner with Constant Contact and can offer discounts and set up.) *

Please provide the usernames and passwords for all Email Marketing services: *

Who do you use for Text Marketing services? *

If you would like any specific images used for photography, please upload them here

Drag & Drop Files, Choose Files to Upload You can upload up to 20 files.

Are you interested in Social Media posting, Weekly Tips, or Blog/News postings? *

Are you interested in any additional Graphic Design services, such as Banners, Business Cards, Logo Design, etc? *

Please list any additional services/products you sell besides Annuities and IULs if you would like those included (such as wealth management, medicare, health insurance, etc.)

List all Charities that you contribute to

Upload Charity logos, if you have them.

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

I acknowledge that payment is due within 30 days of receipt of the invoice. After 90 days of non-payment, a penalty of 10% interest, accrued monthly, will incur. After 180 days, Revolution Media will cease to conduct business with me and may report the debt to a collection agency. *

I acknowledge that payment is due within 30 days of receipt of the invoice. After 90 days of non-payment, a penalty of 10% interest, accrued monthly, will incur. After 180 days, Revolution Media will cease to conduct business with me and may report the debt to a collection agency.

Signature *

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Name

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REVOLUTION MEDIA, LLC

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