Agency Referral

Get the Agency Referral Packet and Apply Today

Learn About the Agency Referral Program

Filling out this form assumes you are already registered as a Referring Agent with Berlin & Denys Insurance.

Please fill out all required fields. A copy will be sent to your referring agent, the agency administrator and the referring agency.
If further instructions are needed please leave them in the special
instructions field.

The information you provide populates our commission system. Please use only legal names and correct phone and email addresses. This will help us pay you promptly. You must use this form to be paid.

Client Information

Client Legal First Name

Client Legal Last Name

Client Phone

Client Email

Referral Agent - Pick one from the drop down list

This is your writing agent. This agent will contact, write and service your client.

You must select from this list only

Policy Types

Please check only the fields that you want your referral agent to propose.
If not checked we will not propose coverage.

Special Instructions

Referring Agent Information (Agent Referring the Client)

Referring Agency

Referring Agent First Name

Referring Agent Last Name

Referring Agent Phone

Referring Agent Email

I attest that the client I am referring has given their express permission for a Berlin & Denys Insurance agent to call or email them. The client should understand that the agent will leave a voicemail if they do not answer. The client should be prepared to call the agent back if they want coverage or quotes. Agent will make contact within 24-48 hours. I understand that no referral fee can be paid on Medicare Advantage plans as per CMS.