Supply Order Form

AGENT SUPPLIES CREDIT CARD AUTHORIZATION FORM (SHIPPING INCLUDED)

Agent Name

Email Address

Date

$99.00-STARTER PACKAGE (Best Value for New YIG Agents)$99.00-STARTER PACKAGE (Best Value for New YIG Agents)Flip Chart Laminated and Bound for Ease in Presenting to Your Prospects
Personalized Dual Sided ID Badge with Vinyl Pouch and Lanyard
(a). **Please upload headshot and email to TParella@YOURInsuranceGroup.net**
(b)***AGENT'S STATE LICENSE #
1000 Business/Prescription Discount Cards with Color Printing on Both Sides
250 Delivery Notices (10 pack of 25 sheet)

$31.00-DELIVERY NOTICES 10 packs of 25 sheets$31.00-DELIVERY NOTICES 10 packs of 25 sheets

$18.00-ID BADGE You get your personalized dual sided id badge, vinyl pouch and lanyard.$18.00-ID BADGE You get your personalized dual sided id badge, vinyl pouch and lanyard.

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$18.00- Flip Chart Laminated and Bound for Your Ease in Presenting$18.00- Flip Chart Laminated and Bound for Your Ease in Presenting

$40-1000 Business Cards with Prescription Discount on reverse side$40-1000 Business Cards with Prescription Discount on reverse side

***Business Card Title

Phone

Fax

Address (optional)

Total Cost

I, the undersigned cardholder, authorize YOUR Insurance Group, LLC to charge my credit card for services provided. *I Consent

Cardholder Name (required) *

Credit Card Number (Required) *

Expiration Date (Required) *

Card Security Code (Required) *

Billing Address (Required) *

Billing City, State, Zip: (Required) *

Phone Number (Required) *

Cardholder Signature (Required) *

Or, Print & Send order form to YIGLeads@YOURInsuranceGroup.net or fax to 224-723-5951 or 1-847-897-2016
Estimated Time of Delivery: 7-10 Business Days