Compliance Lead Form

Lead Identification

Universal Lead ID Unique identifier (UUID format)

Event Date

Event Time

Consumer Information

First Name

Last Name

Email Address

Phone Number

Event Details

IP Address Consumer's IP address at time of event

Location City, State (derived from IP)

Visual Playback

Auto-generated Playback Link

Link will appear here after entering Lead ID

TCPA Disclosure Statement

Labeled TCPA Disclosure Statement

THIS IS A SOLICITATION FOR INSURANCE. BY SELECTING THE CHECK BOX, YOU REPRESENT THAT YOU ARE 18+ YEARS OF AGE AND AGREE TO THE PRIVACY POLICY AND TERMS & CONDITIONS. BY SELECTING THE ABOVE CHECK BOX “YOU AGREE BY YOUR ELECTRONIC SIGNATURE THAT YOU GIVE EXPRESS WRITTEN CONSENT TO RECEIVE MARKETING COMMUNICATIONS REGARDING INSURANCE PRODUCTS AND SERVICES INCLUDING BUT NOT LIMITED TO MEDICARE ADVANTAGE, MEDICARE SUPPLEMENT, AND PRESCRIPTION DRUG PLANS THROUGH THE USE BY AUTOMATIC DIALING SYSTEM AND PRE-RECORDED CALLS AND ARTIFICIAL VOICE MESSAGES FROM TOP NOTCH INSURANCE DEALERS AT THE PHONE NUMBER AND E-MAIL ADDRESS PROVIDED BY YOU, INCLUDING WIRELESS NUMBERS, IF APPLICABLE, EVEN IF YOU HAVE PREVIOUSLY REGISTERED THE PROVIDED NUMBER ON THE DO NOT CALL REGISTRY. SMS/MMS AND DATA MESSAGING RATES MAY APPLY. YOUR CONSENT IS NOT REQUIRED TO GET A QUOTE OR PURCHASE. TO RECEIVE QUOTES WITHOUT PROVIDING CONSENT, PLEASE CALL AT 855-650-4435 TTY:711 (MON-FRI 9AM-6PM EST). CARRIER DATA RATES MAY APPLY. TCPA LEADID'S ARE USED WITH THE INFORMATION FOR COMPLIANCE. YOU CAN REVOKE YOUR CONSENT BY FILLING OUT THE OPT-OUT FORM.

Copy and paste the exact disclosure text from the lead form

Verification & Consent