Website Order Form

Personal Information

Leave blank if you do not have an Agency name or if you would rather your name be used as your brand.
The phone number you would like us to contact you by.
The email you would like us to contact you by.
The phone number you would like displayed on your website, if different from your contact phone.
The email you would like displayed on your website, if different from your contact email.
This is the address we will display on your website. If you do not wish to give a precise street address, leave this box blank and we will use only the city and state provided below instead.

Customization

If you would like the colors matched to your logo, please say so.
A domain is your website url/address. If you own your domain and have an email address or other service connected to your domain, please let us know in the domain name box. We don't want to break any current services you may have! Please note: Due to CMS compliance rules, domains with the word 'medicare' are prohibited.
Give us a suggestion and we'll see if it's available.
In order to have the correct compliance statement on your website, please select the option that best applies to you.

The compliance statements are as follows:

If you offer ALL plans in the area: ‘‘Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. You can always contact Medicare.gov, 1–800–MEDICARE, or your local State Health Insurance Program for help with plan choices.’’

OR

If you only offer SOME of the plans available in the area: "We do not offer every plan available in your area. Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. Please contact Medicare.gov, 1–800–MEDICARE, or your local State Health Insurance Program to get information on all of your options.’’

If you have a logo, please upload it here.
To customize the image in your About Us section, please upload a personal or team photo here.

If you do not have custom About Us verbiage, you can use the template below. Copy and paste the following text into the box above and customize appropriately.

My name is [NAME], and I have worked in the insurance industry for [NUMBER] years. I understand that in today's market, there is not a one-size-fits-all answer when it comes to insurance, and I am confident that my insurance provider partners and I can come up with an affordable solution for you and your family or small business.


I work with A+ rated insurance providers and can offer insurance coverage that will meet your needs and save you money. Based in [CITY], [STATE]. I am an independent insurance agent licensed to represent products in [STATE/STATES], and I look forward to working with you.


Optional Verbiage Start I volunteer at my local [FILL IN THE BLANK], and I love to [FILL IN THE BLANK] in my spare time. My hobbies include [HOBBY], [HOBBY], and [HOBBY]. Option Verbiage End


If you have any questions, please don't hesitate to call or email me and begin the process of providing your family the peace of mind that comes from being protected.

Terms & Conditions

According to the terms as outlined by the All In Program, I am to be provided with a free website with Messer Financial Group – a $339 value. At such time as I no longer qualify for the All In Program, my website will be disabled immediately.

I understand that my website maintenance is included in this agreement. Maintenance is as follows:


Tier 1: Contact changes – includes phone number, email, address – limit 3 changes per calendar month


Tier 2: Content changes – includes text changes supplied by the site owner – limit 1 change per month


Tier 3: Aesthetics changes – includes photos/images – up to 5 changes per year


Tier 4: Overhaul – includes color change, photos/images, textual changes – 1 per year

If you do not see a success message after hitting the "Submit" button, your form has not submitted. Please check that all required fields (marked with an astrisk*) are filled - the form will not submit unless all required fields are filled. Thank you!