Agent Lead Profile Request Form

Personal Information

Your contact information is required so that we can find your BrokerOffice account and/or contact you with any questions that we may have.

* First Name

* Last Name

* Phone Number

* Email Address

Type of Lead Options

Please select the type of leads you would like added to your ProspectZone leads. The price listed here will be your base price. All the other variables listed below will be added to this base price to create the total cost of the leads you will be receiving. By selecting this base price you are authorizing Norvax to make the appropriate changes, and you understand that your lead price may increase by the prices listed below.

* Please select if you would like shared or exclusive leads. Shared leads are sold to no more than 5 agents. Exclusive leads are sold to only you.

Shared Leads - $6

Exclusive Leads - $13

Geographic Lead Options

Please select the geographic lead variables you would like added to your ProspectZone leads. By selecting these variables you are authorizing Norvax to make the appropriate changes, and you understand that your lead price may increase by the prices listed below.

* Please select if you would like to receive leads from statewide, specific counties or zip codes.

Statewide - No additional cost

Counties - $2

Zip Codes - $4

If you have requested statewide leads, then please select all the states would like to receive leads from. Statewide leads have not additional cost from the base prices listed above.

If you have requested leads from specific counties, then please type out all the counties would like to receive leads from. County leads are an additional $2.

If you have requested leads from specific zip codes, then please type out all the zip codes would like to receive leads from. Zip code leads are an additional $4.

Demographic Lead Options

Please select the demographic lead variables you would like added to your ProspectZone leads. By selecting these variables you are authorizing Norvax to make the appropriate changes, and you understand that your lead price may increase by the prices listed below.

* Minimum Age of Lead?

Please add a minimum required age. - $.50

I will accept leads with no minimum age.

Minimum age requested if selected above.

* Maximum Age of Lead?

Please add a maximum required age. - $.50

I will accept leads with no maximum age.

Maximum age requested if selected above.

I would like to filter out:

Filter Out Uninsurable Consumers* - $1.50

Filter Out Individuals - $1.50

Filter Out Families - $1.50

*If choosing to received Uninsurable leads, you will not be able to return leads to ProspectZone for health reasons. You may return leads that have invalid contact information or are duplicates.

I would like only consumers that currently:

Have existing health insurance. - $1.00

Do NOT have existing health insurance. - $1.00

These are the same materials that we use in our tutoring services, but you may buy them separately if you wish.

Terms and Conditions

When you push "Continue," you will see the total cost per lead based on the parameters you have set above. If you would like change any of these parameters, you will still have a chance to before you submit your request to Norvax.

By confirming this request, you understand that this will be the price of the leads that you receive. You will receive an email confirmation within 2 business days that this has been updated to your lead profiles inside of BrokerOffice. If you turn on your leads before you receive this confirmation, then your specifications will not be set and you may receive leads out of the specifications you have outlined above.

* Indicates Response Required

Alabama	Alaska	Arizona	Arkansas	Colorado
Connecticut	Delaware	District of Columbia	Florida	Georgia
Illinois	Indiana	Iowa	Kansas	Kentucky
Louisiana	Maryland	Michigan	Mississippi	Missouri
Nebraska	Nevada	New Mexico	North Carolina	Ohio
Oklahoma	Pennsylvania	South Carolina	South Dakota	Tennessee
Texas	Virginia	West Virginia	Wisconsin	Wyoming