LifeCo: Your Agent-Oriented Independent Marketing Company: IMO providing Lead Programs for Independent Agents: Help Prospecting for Insurance Leads, and leads for insurance agents: Life Insurance, Medical, Term and Disability Insurance Lead Programs.


Friday, May 9, 2008		Contact Us

Agent Profile Form

Agents please complete the following profile.

Required fields to submit the form are indicated by *.

Date:*

First Name:*

Last Name:*

Agency Name:

Street Address:*

City:*

State:*

Zip Code:*

Phone Number:*

Fax Number:

Email Address:*

Lead Programs:*
(check all that apply)

Annuity:
Life:	Mortgage Life:	LTC:

Company's Info Requested:*
(check all that apply)

Allianz
American General
American National
AmerUS Annuity
Chesapeake Life
Empire General
F&G Life
Guaranteed Issue
Impaired Risk Company
Indianapolis Life
ING USA Annuity
Midland National
People's Benefit Life
Shenandoah Life
West Coast Life
Other

Current Market Information

Please complete the following information regarding your current work.

Current Market

Market Niche:*

Premium Production:*

Current Company:*

Current Commission Level:*

Comments:

LifeCo Insurance Marketing 7400 E. Caley Avenue Suite 170 Englewood, Colorado 80111
303.224.0788 800.234.1480 Fax: 303.224.0789