Landing Page Request Name(Required) First Last Email(Required) Phone(Required)Agency Name (If applicable)Products that you'd like to represent (Products must be contracted with MCC)(Required) Medicare Advantage Medicare Supplement Dental Vision Hearing Cancer, Heart Attack, & Stroke Accident Long-Term Care Hospital Indemnity Life Insurance Annuities Would you prefer a landing page (1 page) or a website (up to 3 pages)?(Required) Landing Page Website What pages would you like for your website? (Choose 2. Home page is already included) About Contact Products Our History Get a Quote Events (Agent Updates) Agent Title(Required) Licensed Sales Agent Independent Sales Agent Independent Sales Representative Licensed Sales Representative Will you be providing a headshot? Drop files here or Select files Max. file size: 50 MB. Will you be providing a logo? Drop files here or Select files Max. file size: 50 MB. Will you be providing a bio? Drop files here or Select files Max. file size: 50 MB. Website Colors (Choose up to 3. NO Red, White, and Blue)(Required)Site Theme Beach (Light) Beach (Dark) Mountains City Administrative (Law Office) Medical Forest Other (put in notes) Domain Name(Required)Calendly URLpURL(Required)Expedite Request?(Required) Yes - Website Issue/Carrier Issue Yes - PR Related No NotesConsent(Required) By requesting a landing page you agree and understand the following: I acknowledge that landing pages and websites are limited to 3 pages per agent. I understand that MCC Brokerage will have continuous access and ownership of the landing page or website for compliance and updates. I understand that by submitting this form to request a landing page or website, I must be contracted with at least two (2) carriers under MCC Brokerage, and I waive my ability to obtain an immediate release. If I request a release, MCC Brokerage has 90 days to deactivate my website or landing page, and unpublish it from my custom domain (if applicable). I understand that all information included in the landing page or website must remain compliant, and it is my responsibility to notify MCC Brokerage's marketing team of any changes in contracts, allegations, addresses, or other compliance violations. I understand that the creation of a landing page or website does not guarantee enrollments through this site.(Required)Type Your Full Name To Sign(Required)Date Signed(Required) MM slash DD slash YYYY CAPTCHA Δ
