Agent Registration

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First Name

First name is required

First name must be between 2 and 200 characters

First name can only contain letters, numbers, spaces, or -

Last Name

Last name is required

Last name must be between 2 and 200 characters

Last name can only contain letters, numbers, spaces, or -

Street Address

Street address is required

Street address must be between 4 and 200 characters

Street address can only contain letters, numbers, spaces, -, #, &, /, and ,

County

County is required

City

City is required

City must be between 2 and 200 characters

City can only contain letters, numbers, spaces, -, #, &, /, and ,

State

State is required

State must be 2 characters

State can only contain letters

Zip Code

Zip code is required

Zip code must be 5 characters

Zip code can only contain numbers

Primary Phone

Phone number is required

Phone number must be in 999-999-9999 format

Email address is required

Email address must be between 5 and 200 characters

Email address must be in name@domain.com format

Who is your current Auto Insurance provider?

Current auto insurance provider is required

Please specify

Current insurance provider is required

Current insurance provider must be between 2 and 200 characters

Current insurance provider can only contain letters, numbers, spaces, -, #, &, /, and ,

When is your Auto Insurance up for renewal?

Renewal date is required

Renewal date must be between 8 and 10 characters

Renewal date is invalid

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