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    Company Address and/or Desired Office Location
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    Current Channel
    Select OptionIndependentCaptive
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    Which Carrier?
    State FarmFarmersAll StateAmerican FamilyNationwideFarmers BureauOther
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    Membership Option Interested In
    Select OptionOption 1Option 2
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    Years of Insurance Sales Experience
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    Years as an Agency Owner
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    Current Pain Points
    Carrier AccessCommission CutsClose RatiosReducing MarketsDecreasing RevenueOperation SupportStarting My Own Agency
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