Website Request URLThis field is for validation purposes and should be left unchanged.Name(Required) First Last Email(Required) Phone(Required)Agency Name (If applicable)Manager Approving Your Request(Required)Choose from list...Edward HaylockPatricia FaustJoe RamirezNelly CastilloJade PowisChoose Your Title(Required)Independent Sales AgentIndependent Sales RepresentativeLicensed Insurance AgentLicensed Sales AgentProducts that you'd like to represent (Products must be contracted with MCC)(Required) Ancillary Plans Annuities Hospital Indemnity Life Insurance Long-Term Care Medicare Advantage Medicare Supplement Is This a Request for a Landing Page or a Website?(Required)Landing Page- Only One (1) PageWebsite- Up to Three (3) PagesThis field is hidden when viewing the formIs this a Request for a Landing Page or Website?(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) This field is hidden when viewing the formAgent Title(Required) Licensed Sales Agent Independent Sales Agent Independent Sales Representative Licensed Sales Representative Upload a Headshot Drop files here or Select files Max. file size: 50 MB. Upload Your Logo Drop files here or Select files Max. file size: 50 MB. Add a Bio(Required)This field is hidden when viewing the formWill you be providing a bio? Drop files here or Select files Max. file size: 50 MB. Choose Your Colors(Required)1234567891011121314151617181920212224This field is hidden when viewing the formWebsite Colors (Choose up to 3. NO Red, White, and Blue)Choose Your Theme(Required)Beach Dark (B&W)Beach StandardCityMountainModern SpeedSimple SerifSimple SansOther- Specify In NotesThis field is hidden when viewing the formSite Theme Beach (Light) Beach (Dark) Mountains City Administrative (Law Office) Medical Forest Other (put in notes) Domain NameCalendly 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 5(5) 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
