Q1 2026 Client Roster Application

Please answer honestly. We only accept 10 active partners at a time to maintain compliance and result standards.

1. My position is... (Required)

2. Company name (Required)

3. Lines of business (Select all that apply) (Required)

P&C Life Commercial Health Medicare Other

4. States licensed in (Required)

5. How big is your team? (Required)

6. Current lead sources (Select all that apply) (Required)

Referrals FB/IG Ads Google Ads Lead Vendors Cold Calling Email Other

7. Estimated monthly marketing budget for 2026? (Required)

8. Which area worries you most right now? (Required)

TCPA/FCC FTC CCPA/CPRA CAN-SPAM Meta Special Ad Category Unsure

9. Biggest obstacle today (Required)

10. My full name is… (Required)

11. Email (Required)

12. Phone (Required)

13. Notes for Milan (Optional)

By checking this box, I consent to receive texts and calls (including automated messages) related to my account, orders, or services I have requested from MILAN KRKLJEŠ PR MXK DIGITAL. I understand consent is not a condition of purchase. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt out. See our Privacy Policy and Terms & Conditions. (Required)

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others from MILAN KRKLJEŠ PR MXK DIGITAL. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt out. See our Privacy Policy and Terms & Conditions. (Required)

Q1 2026 Client Roster Application

Application Received