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AGENT LEADS ORDER FORM - SOCIAL MEDIA HEALTH
PATRIOT INSURANCE GROUP
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AGENT NAME: *
ORDER DATE: *
MM
/
DD
/
YYYY
Email Address for PayPal *
Leads will be generated within a 50 mile radius from the zip code below provided: *
Type of Leads *
Quantity (Minimum 20): *
TOTAL COST: *
BY SENDING IN THIS LEAD ORDER YOU ACCEPT THE TERMS AND CONDITIONS OF THIS AGREEMENT *
E-SIGNATURE - PLEASE TYPE IN YOUR FULL NAME BELOW TO AGREE TO ABOVE AND BELOW TERMS *
ADDITIONAL NOTE OR MESSAGE:
TERMS AND CONDITIONS
*Terms and Conditions – by submitting this form you understand that the vendor charge your credit card the amount listed on this form and by submitting this form acts as your consent to do so. Your order will not be placed in the queue until payment is rendered. Due to changing market conditions and your chosen counties/states, order fill times may vary. Leads usually take 3-5 days to start arriving and then 5-10 more days to fill although this can increase due to vendor.   Minimum order 20 leads.
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