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miQuotes Contract Request Form
Date  :
Referring Agency  :
Please Contract the following new Agency/Agent
1. miQuotes Platform
2. Agency Name  :
3. Agency Address  :
 
4. City  :
5. State  :
6. Zip  :

7. Phone  :
 
8. FAX  :
 
9. Contract Signatory & Title  :
10. For all States and/or carriers miQuotes pays direct commission to Agency, what portion of the available commission will Agency receive? %
11. Will Agency include discount medical benefits through Peoples Health Express on its miQuotes website?
12. Additional Comments  :

                
   
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