First Name:
Last Name:
Company:
Checks Payable To:
Email:
Phone:
Address:
City:
State:
Zip:
Country:
URL where banner will appear:
Where did you hear about us?
Choose a Password:

I understand that I may not promote these products/services or this Affiliate Program by sending unsolicited mailings (SPAM).

1) Which products are you interested in promoting?

Life Insurance
Long Term Care Insurance
Disability Insurance
401K
Annuities

2) Where will these promotions be placed? (example: Web page url, email newsletter, etc.)

3) Which type of marketing creatives are you interested in using?
Example: banners, text link, seamless quote form,

Banners
Text Links
Seamless Quote Form

Other marketing Creative (if other, please explain)

4) How will you get people to view these promotions (i.e. get visitors to your site etc.)?

5) How many leads do you expect to generate daily or monthly?

6) Do you offer an incentive program or sweepstakes? If so, please explain your program.

7) Please complete the W-9 tax form located on the following webpage and fax it back to 800-735-6119 Attn: Accounting This is required for all US affiliates (www.irs.gov/pub/irs-pdf/fw9.pdf)

Yes, I am a US Affiliate and agree to fax you my W-9
(800-735-6119).

No, I am an Affiliate outside the US.

Optional: Enter the email addresses of up to five of your friends, letting them know about this affiliate program. If they follow the email link here and sign up, they will automatically become part of your second tier!

Email #1:
Email #2:
Email #3:
Email #4:
Email #5:

It generally takes about 2-3 business days for a program to be reviewed.