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.

    If you do not have the information for a not required field, skip that question instead of entering filler like "not yet" or "under construction".

    You can update information directly in HubSpot after this form has been submitted.

    Affiliate

    Proposed Agency Name*

    Principal First Name*

    Principal Last Name*

    Principal Agency Partner(s)*

    Domiciled State*

    (Including the Principal) Total Number of Agency Staff upon Signing*


    Office Information

    Office Street Address*

    Office Street Address 2 (Suite #)

    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*

    Free months in Epic

    Free months in EZLynx

    Planned Agency Launch Date*

    Referred By

    Referral Payment Type

    Contract Type*

    Base Commission Split*

    Bonus Commission Split*

    Bonus Premium Requirement*

    Important Notes or Concessions:*

    Any Existing Codes or Books?*