Mad Money

This form is to be used by a BASIC Ops employee to refer new business inquiries to the Sales Dept. Please fill out all required fields and send any additional info to scarlson@basiconline.com
Your Name*
Your BASIC Email*
Requested Service*
How did you get this lead?*
- Email
- Phone Call
- Networking
- Personal Relationship
PDF of email*
In Outlook choose file, Save as Adobe PDF, save to your desktop, and upload PDF
Max. file size: 500 MB.
Please describe relationship or interaction*
Synopsis of phone call*
Is the person that contacted you an agent or broker?*
- Yes
- No
Please fill in the Broker/Agent's information on the fields below NOT that of their client.
Broker/Agent Name*
Agency*
Broker/Agent Email*
Broker/Agent Phone Number*
Broker/Agent State & Zip Code*
State / Province / Region ZIP / Postal Code
Client/Prospect Company Name
Please fill in the information on the fields below.
Company Name*
Contact Name*
Email*
Phone*
Are they a current client?*
- Yes
- No
- Unsure
What service(s) do they currently have?*
Client/Prospect State & Zip Code*
Please use the location of the person contacting you.

State / Province / Region ZIP / Postal Code
Total number of employees
Always good information to ask
Any Additional Information

Δ

Scroll to top