[Breathe Agent Production] – Breathe Insurance

Breathe - Agent Production

New Business Input

Agent Name*
Client Name
Client First Client Last
EZlynx App ID
Transaction Type:*
- New Client
- Existing Client/Additional Line
How many policies are you submitting?*
Policy 1

Carrier 1
Policy 1
Effective Date 1:
MM slash DD slash YYYY
Premium 1
Policy 2

Carrier 2
Policy 2
Effective Date 2
MM slash DD slash YYYY
Premium 2
Policy 3

Carrier 3
Policy 3
Effective Date 3
MM slash DD slash YYYY
Premium 3
Policy 4

Carrier 4
Policy 4
Effective Date 4
MM slash DD slash YYYY
Premium 4
Life Insurance

Life Application Count
Total Life Premium
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