RBI Agent Affiliate Program

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INSTRUCTIONS

1. FILL OUT THE FORM BELOW, THEN CLICK SUBMIT.

2. YOU WILL RECEIVE AN E-MAIL SHORTLY THEREAFTER THAT CONTAINS COMPLETE INSTRUCTIONS ABOUT YOUR REPLICATED WEBSITE.

Please fill out the following information.
Your Sponsor Is: QuoteSelect Insurance
Your Sponsor's ID: quoteselect

First Name:	Last Name:
Shipping Address:
Mailing Address:(if different)
City:	State:
Zip Code:	Country:

Phone: (required)

Fax: (optional)

Email Address: (required)

SSN/EIN Number:
(Tax ID) Please use your phone number for Non-US Applicants

No Dashes! Numbers Only!
Example: (123456789)

Choose a Page Name:
For Example: http://reliablebenefits.net/ pagename

DO NOT TYPE THE FULL URL-
JUST THE PAGENAME YOU WANT IN LOWER CASE! (i.e - johndoe)

Please enter a short welcome message for your page.
Welcome to Reliable Benefits, Inc.

Electronic Commission Deposits

Personal checking account users in USA Only

Reliable Benefits Inc. may deposit commissions directly into the checking account below in lieu of mailing paper checks.

Routing # Account #

The bottom line on your check (MICR) contains your Routing & Account numbers.

Contract Agreement

If you would rather view, download or print a PDF copy -click here-

You must read, understand and agree to the terms and conditions of the Independant Distributor agreement. Please type your full name in the box below and click Join.

A copy of this Legal Digital Signature will be maintained in your file, stored at the home office.

ADDITIONAL TERMS AND CONDITIONS: I understand that this agreement will remain in effect until Reliable Benefits Inc. has received a written notice from me that it should be cancelled. To ensure prompt cancellation of my program, this notice must be submitted at least 15 days, but not less than 3 days, prior to my next scheduled payment date. Cancellations can be mailed to RBI 1607 Caraquet Dr. Spring, TX 77386 or faxed to 866-836-0503.

Please Type "Your Full Name"

Note: You will receive an Email soon with your ID# number and Agent Login Password. Please ensure that your email address is correct before submitting, otherwise you will not get this vital information!!

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