Agents & Planners Online Information Form

To send your information to Property Crossing, please fill out the required fields on this form and click the Submit button on the bottom of this page.  The information will be submitted to our employment department and one of our representatives will contact you (via email or phone) as soon as possible.  I. PROSPECTIVE LOAN OFFICER INFORMATION   First Name Middle Name Last Name  Suffix if applicable)  Company Name  Email Telephone FAX Street City: State: Zip Code:    II. PROFESSIONAL INFORMATION   Position Independent Agent Captive Agent MGA/BGA     Specify # Of Agents:  Other    Products Check all the products you or your agents regularly sell. Residential Mortgages Commercial Mortgages  Individual Health Disability Income Fixed Annuities Medical Supplement Term Life Insurance Variable Products Group Health P&C Mutual Funds Stocks Or Bonds Other      Markets Markets you currently target or plan to target.   Current Planned Senior Market Business Market Associations Financial Planning Affluent Market Group/Worksite Mortgage Protection Other              Professional Designations/Licenses Mortgage CLU ChFC LUTC CFP CSA P&C Series 6 Series 7 Other      Years In Insurance or Financial Planning Business 1 - 5 6 - 10 11 - 20 21+ Number Of Current Clients 1 - 50 51 - 100 101 - 250 251 - 500 501 - 1000 1001 - 1500 1501 - 2000 2000+ Annual Insurance or Financial Planning Income Under $50,000 $50,000 - $100,000 $100,001 - $200,000 $200,001 - $300,000 $300,001+    III. SUBMIT   Comments:    Your request for information is also your consent to allow us to contact you by telephone, fax, email, U.S. Mail, or other means for information about Property Crossing services and business opportunities.