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PHONE ROOM DATA SOLUTIONS ORDER LIFE FORM
Patriot Insurance Group
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DATE: *
AGENT NAME: *
AGENT NAME FOR SCRIPT: *
PHONE NUMBER: *
EMAIL ADDRESS TO SEND LEADS: *
EMAIL ADDRESS TO SEND PAYPAL (VENDOR WILL SEND PAYPAL LINK FOR PAYMENT AND START ORDER ONCE PAYMENT IS RECEIVED): *
PREFERRED DEMOGRAPHICS - COUNTY OR STATE'S ONLY (Note: if you list a county/counties please specify the state the county/counties are located in): *
TARGET AREA WITH STATE OR COUNTY: *
NUMBER OF LEADS (MINIMUM ORDER 20): *
TOTAL PRICE $10.00 each *
AGE RANGE (RECOMMENDED 40-85) (Income used will be $30,000 per year plus): *
START DATE: *
DELIVERY METHOD FOR LEADS: *
GOOGLE ADDRESS OR EMAIL ADDRESS FOR LEADS:
ADDITIONAL NOTE OR MESSAGE:
TERMS AND CONDITIONS
*Terms and Conditions – by submitting this form you understand that the vendor will send you a PayPal invoice to the email address you provided on this form and the order will not be placed in the queue to be worked on until payment is rendered. Due to changing market conditions and your chosen counties/states, order fill times may vary. Leads usually take 3-5 days to start arriving and then 5-10 more days to fill although this can increase due to vendor.   Minimum order 20 leads.

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