New Affiliate Intake Form

Please fill out this form to get onboarding started.

    To start, please input the ID sent to you by Hubspot for this new affiliate.

    Affiliate

    Proposed Agency Name*

    Principal First Name*

    Principal Last Name*

    Principal Agency Partner(s)*

    Domiciled State*


    Office Information

    Office Street Address*

    City*

    State*

    Zip Code*

    Office Phone

    Office Fax

    Work Email*

    Website


    Payment Information

    Please restate the Down Payment Amount

    Payment Plan Duration*

    Amount due at Contract Signing*

    Number of Planned Epic Seats Needed*

    Planned Agency Launch Date*

    Number of Complimentary EZLynx/Epic Months*

    Referred By

    Referral Payment Type

    Contract Type

    Important Notes or Concessions:*

    Any Existing Codes or Books?*