Disciplined Advisor proposals can be detailed. Please allow 24 to 48 hours.

 
100% of survey complete.

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* 1. Please enter your contact information

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* 2. Through what IMO or brokerage firm will you likely place this case?

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* 3. Please rate your existing relationship with this client

1 Relationship Scale 10
i We adjusted the number you entered based on the slider’s scale.

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* 4. What program(s) are you interested in presenting?

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* 5. Do you also want detailed InsMark proposals?  (Allow one extra day)

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* 6. Actual Name of Client (if known)

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* 7. Gender (Primary Insured)

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* 8. DOB or Age (Primary Insured)

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* 10. Gender (Secondary Insured, if any)

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* 11. DOB or Age (Secondary Insured, if any)

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* 13. Policy Design (check all that apply)

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* 14. Solve amount (annual premium or annual interest or death benefit or amount of income beginning at a certain age)

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* 15. Qualified Plan Account Balances (if any)

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* 16. Household Net Worth

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* 17. Household Income

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* 18. State

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* 19. Other Residences

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* 20. Other Relevant Case Information

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* 21. I understand that POP, ROP and EOP are copyrighted programs belonging exclusively to Disciplined Advisor Network, and I agree to respect all intellectual property rights, trade secrets, and other rights related to the program as they may be defined and amended from time to time.

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* 22. I understand that any information I receive from Disciplined Advisor Network, to the extent that it is not already in the public domain, is Confidential Information and I shall treat it as such. Accordingly, I agree to use such Confidential Information only to do business with Disciplined Advisor in accordance with Disciplined Advisor's normal rules and procedures, and not to do business on my own, or to share such Confidential Information with competitors of Disciplined Advisor.

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* 23. The Parties agree that the Confidential Information is disclosed “As-Is.”  Nothing contained in this Agreement or in any confidential information shall constitute any express or implied warranty of any kind, including without limitation, any warranty or merchantability, fitness for a particular purpose, or non-infringement.

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* 24. I further understand that neither Disciplined Advisor Network, nor any of its principals or employees, practices law, and accordingly does not offer legal advice. Upon request, Disciplined Advisor may recommend experienced counsel. Clients are encouraged, nonetheless, to seek their own legal counsel, as well as professional tax advice.

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* 25. In consideration for the consideration described above, I understand that, if I am successful in my efforts to sell this case, I will share my commissions with a designated appointee of Disciplined Advisor by placing the name and agent code of said appointee(s) on the application for the agreed upon percentage selected below. My choice of anything greater than 0% indicates my agreement.  Splits may vary from case-to-case. Please discuss with a sales representative before completing this question and submitting this Agreement.

0% 50% 100%
i We adjusted the number you entered based on the slider’s scale.

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* 26. I acknowledge and appreciate that Disciplined Advisor Network may be running proposals, making presentations and otherwise providing support services in cases that may, for any number of reasons, not lead to the sale of POP, ROP or EOP specifically, but may instead lead to the sale of some other similar insurance product or strategy. Nonetheless, if substantial work had begun, such that proposals had been created and discussions had taken place, this Agreement shall nonetheless apply.

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* 27. Print your name to act as your signature and accept the above Agreement

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