First Name *

Last Name *

Preferred Name *

Cell Phone

Referred By: *

Email *

Address *

City *

Resident State *

Zip Code *

Please use this as reference for clarity on which role below you are selecting;

Partner Agent (Most Common): As a Licensed Agent, you will be partnering with Main Line Benefits and receive all the support needed to succeed
Independent Broker: You will run your own business and use Main Line Benefits as a source of carrier contracting and some support
Sub Agent: As a Licensed Agent, you want to work under another agent where they will give you support to begin building a book-of-business
Assistant (Licensed or Not): You will typically work an hourly or salary wage to help an Agent in their day-to-day tasks

Which role or capacity are you interested in working with us? *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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