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I agree to the Insurance Agent Website Offer for a one time setup fee of $300.00 and $20.00 hosting per month (no commitment required).

CONTACT INFORMATION:

Company Or Agent Name to Use in Website Header:

Individual's Name if Different from Above:

Address to Publish:

City:

State or Province:

Zip Code:

Country:

Billing Address for Our Records Only (if Different From Above):

Primary City or Region for Your Business (This is for search engine purposes. For example, the address for Griffin Web Design is in Sunny Side, Georgia, but that is a very small suburb. Our best search term geographically would be Atlanta or Griffin, Georgia.)

Current E-mail Address For Our Records Only:

Telephone Number (or Numbers) To Publish:

Any Additional Telephone Number for Our Records Only:

Fax Number to Publish:

Office Hours to Publish:

Please list the state(s) in which you are licensed:

TWO WEBSITE NAME OPTIONS:

NEW WEBSITE NAME:

If you do not already have a website name, we can register one for you. The initial one year domain name registration is included.

Please Note: We cannot register your website domain name until we have received payment for your setup fee.

Please give us your first choice of website names. Feel free to give us second or third choices as well. We will check the availability of your desired name(s). If one of your listed choices is not available, we will check similar names and contact you to assist in your final choice:

-OR-

EXISTING WEBSITE NAME:

If you have already registered a website (domain) name, please tell us what it is. (Be sure to include the ending, such as .com, .org, or .net):

Please specify the Domain Name Registration Company you used (such as GoDaddy.com or NetworkSolutions.com) and the username and password for the domain name record.

E-MAIL PREFERENCE:

Once you have your own website name, for no additional charge, you can have one or more e-mail accounts setup that use the website name, such as contact@mycompany.com or info@mycompany.com or sales@mycompany.com. We usually recommend creating an account such as one of these because it is more professional for people to reach you from your website. It can begin with anything you'd like and will end in the @ sign and whatever your website address is. Please specify what beginning you'd like for your e-mail address:

@mycompany.com (whatever your web address is)
(Fill in "info" or "contact" or "sales" or some other generic department name.)

We will set up the first e-mail address for you and send you the login information. You can create additional email addresses yourself by logging in to your website's control panel. We will send you the login once your website hosting account has been set up.

PHOTO:

The insurance agent website includes a spot for an agent photo in the right column. (See the design sample.)

Click the browse button to send your photo to us with this signup form. If you're not ready to submit your photo now, you may to us later for no additional charge.

PAGE NAMES:

You get a choice of what your five pages will be. The starter site comes with these pages: Home Page, Insurance 101, Our Services, Return of Premium Term Life, and Quick Quote. If you would like to change the page titles/link names, just list what you'd like them to below and we'll make these changes for you for no additional charge. If you'd like to change the page titles/link names later, the charge is only $22.50.
Home Page Insurance 101 Our Services Return of Premium Term Life Quick Quote

PAYMENT OPTIONS:

Please note, we require the setup fee in order to initiate a new custom web design project. Initial payments may be submitted to Griffin Web Design, P.O. Box 329, Sunny Side, GA 30284-0329, or may be sent via PayPal (a special link is available on the confirmation page after you submit this form), or you may contact us for a debit authorization form so that we can debit your bank account. All of these options will be repeated on the confirmation page when you submit this form.

We have the same three payment options available for your $20.00 monthly hosting service. Please specify how you'd like to pay your monthly hosting from the three payment options below:

Payment Option #1 - INVOICE:
Please send us a monthly invoice.

Payment Option #2 - AUTOMATIC ELECTRONIC CHECK:
I would like to sign up for automatic bank drafts. I will download the debit authorization form and fax it in after completing this signup form. (ACH direct payment processing will always be debited on the 5th of each month or the next business day after the fifth, whichever occurs first.)

Payment Option #3 - PAYPAL (Visa, MasterCard, Discover, American Express, or E-Check):
PayPal monthly automatic credit card payment. Click here to sign up for PayPal payments for monthly hosting fees. (A special link is available on the confirmation page after you submit this form if you'd like to pay for your initial setup fee via PayPal as well.)

How did you did you find out about this offer?

Mark Rosenthal of Rosenthal Financial Services
Google or Another Search Engine
Other

COMMENTS:
Feel free to add any additional comments or questions.

Security test. Please identify the pictures:

By submitting this form, I am stating I am a qualified representative of the company and/or website listed, I have read the Terms of Service, and I agree to all of the above.

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