Agent Name

Agent Email

Agent Phone Number

Client First Name

Client Last Name

Life Insurance

Health Insurance

Group Health

P&C (Personal Lines)

P&C (Commercial Lines)

Carrier Name

Policy Number

Date Submitted to Carrier

Effective Date

Annualized Premium

Modal Premium (Client's Draft)

Payment Frequency

Was a Relationship Manager involved? If so, add the full name of the Relationship Manager

Was a Center of Influence involved? If so, add the full name, email address, and phone number, and COI type ( CPA, Financial Advisor, Mortgage Broker, Realtor, Attorney, etc.)

Notes

Attach File