Insurance Marketing Corp. - Contract an Agent

CONTRACTING AS AN AGENT (Michigan Only)
Name:
Agency Name:
Address:
City:
State:
Zip Code:
Phone:
Fax:
E-mail:


I would like product / contracting information on the following insurance carriers and their products:

Individual Medical		Other Individual Products
Fortis American Medical Security Continental General Midwest Security		IMG Fortis STM Senior Life Cancer Care

Group Health		Group Ancillary
Fortis Midwest Security AMS Continental General		IMG Fortis US Life GE

Medicare Supplements		Long Term Care
Continental General Conseco		States Life Allianz

Individual Term Life
North American First Penn Pacific Old Republic Banner		Kemper/Zurich U.S. Financial Security-Connecticut

How many individual cases do you sell a year?
How many Group cases do you sell a year?
What product lines do you produce a significant amount of business in? (please check all that apply)	Individual Medical Individual Life Individual Dental Short Term Medical Group Health Group Ancillary Medicare Supplements Long Term Care