First Name *

Last Name *

Phone *

Email *

Website

Company Name *

Which U.S. states are you licensed in? *

List every state where you can legally sell life insurance.

Priority states for this order

If you prefer specific states for the first test, list them here.

Preferred age range *

Any hard age cap?

Best email for lead delivery

Leave blank if you want to use your main email

Which CRM do you use?

Leave blank if you don't have any

Are there any specific criteria you want leads to meet?

List any specific answers, filters, or preferences you want us to consider. We’ll confirm what is realistic before launch.

What times do you want to receive leads? (Leave empty if the whole day is fine)

Please include your time zone

Should we treat your delivery time window as strict? *

Strict — only deliver leads during the time window I listed

Flexible — delivery outside the window is okay if needed

Preferred, but occasional exceptions are okay

Confirm on kickoff call

Strict delivery windows may slow down lead volume. Flexible delivery can help fulfill the order faster, but leads may arrive outside your preferred hours.

Order delivery preference *

Spread evenly over the order

As fast as possible during my available hours

Start slow, then increase if quality looks good

Confirm on kickoff call

License confirmation *

I confirm I hold active insurance licenses in the states listed above and will only contact leads in states where I am properly licensed to sell life insurance.

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