New Client Check List

Full Name *

First

Last

Group Name *

Date / Time//

Products Sold: ( Code EE, EC, ES, EF )

Complete Rates for Each Product

Health Insurance Code:

Rate:

Hospital Assure Code:

Rate:

Active Care Code:

Rate:

UL2 Code:

Rate:

Accident Code:

Rate:

Critical Illness Code:

Rate:

Cancer Code:

Rate:

Dental/ Vision Code:

Rate:

Credit Repair Code:

Rate:

SEO Code:

Rate:

Payroll Code:

Rate:

NBBA Dues $24.95

Monthly Total : *

Notes