REV MEDIA GROUP

Website Ordering

Fill Out The Form Below

Your Company & Agent Information:

What is the legal name of your entity/company? *

Agent Name *

First

Last

Agent Email *

Agent Mobile Phone Number *

Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Upload Logo *

Click or drag files to this area to upload. You can upload up to 3 files.

Additional Staff

Phone number you would like listed for all marketing materials *

Email you would like listed for all marketing materials and where form leads will be sent? *

What is your License number as well as the business' license number? We need all license numbers for the disclaimer that is in the footer of the website as well as any marketing material we create for you. *

Please provide any disclaimers you use. *

Please upload a copy of your department of insurance license certificate. *

Click or drag a file to this area to upload.

Do you own your URL? If so, please provide the login and password for your domain name (such as a GoDaddy Login). *

Who is your Email Provider? (For example, Gmail, Office 365, Outlook, AOL, Yahoo, etc.) *

Who are you using for Email Marketing (Mailchimp, Bomb Bomb, Constant Contact, etc)? (We are a partner with Constant Contact and can offer discounts and set up.) *

Please provide the usernames and passwords for all Email Marketing services: *

Who do you use for Text Marketing services? (We are a partner with EZ Texting and can offer 1/2 price credits.) *

If you would like any specific images used for photography, please upload them here

Click or drag files to this area to upload. You can upload up to 20 files.

Are you interested in Social Media posting, Weekly Tips, or Blog/News postings? *

Are you interested in any additional Graphic Design services, such as Banners, Business Cards, Logo Design, etc? *

Please list any additional services/products you sell besides Annuities and IULs if you would like those included (such as wealth management, medicare, health insurance, etc.)

List all Charities that you contribute to

Upload Charity logos, if you have them.

Click or drag files to this area to upload. You can upload up to 10 files.

Website Ordering:

Who should we correspond with about this job? *

First

Last

Email *

Phone *

Which package are you ordering? (view details of each package below) *

Cookie Cutter Package $1,000
Mid-Level Package $4,500
High Level Package $6,500

Billing:

Should we bill the Revolution directly? Please note that the Revolution pays IMMEDIATELY, so if you would like to review the invoice first, select No. *

Name