Atkins And Associates 540-286-2323
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Referral Contest Form:
Refer a friend to us for an insurance quote and be entered into our monthly "Referral Contest".
Simply complete the form below for each referral.
Personal Insurance Referrals receive 1 entry each.
Business Insurance Referrals receive 3 entries each.
Referrals received one month, will be entered into the drawing for the prize that will be awarded the following month.
Example: For the referrals we receive in January... prize will be awarded in February.
No limits on the amount of referrals someone can submit.
The only stipulation is that you must have cleared it with your "referral source", that it is okay for us to contact them, based on your referral to us.
Winners will be notified by your choice of email or phone call. We will also announce it on Facebook and in our Newsletter.
Good Luck & Thank You For Participating!
Name Of Your Referral
The Referral's Business Name (if you are referring for Business coverage)
The Referral's Email Address:
The Referral's Phone Number
Your Email Address
Your Phone Number
If you are a Winner, would you like us to contact you by:
Indicates required field
Have you cleared it with your Referral Source that it is okay for us to contact them, based on your referral to us? ***Please note that ONLY "cleared referral sources" are able to be entered into the drawing)
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