Submit Your Agency

Your Information
Agency Name
First Name
Last Name
Phone Number
E-mail
Website

Install Questions
How many locations do you have?
What time does your office open?
How many users in your office
How many users will be accessing IMS at any one time?
Would you like to sign up for Transformation Station? Yes No
Does your office use a comparative rater, if yes which one?
Is the office using Microsoft Outlook? Yes No
Is the office using Microsoft Word? Yes No
Your server is (Windows 2003, 2008, XP, 7)
Does your server have the latest patches loaded? Yes No
Scanner Type
What is your preferred method of contact E-Mail Phone Mail
A nearby hotel - (Hampton Inn, etc.)

Please list your expectations for training (what do you expect to learn?)

List Your Users
First Last E-Mail Title Newsletter?
01) Yes No
02) Yes No
03) Yes No
04) Yes No
05) Yes No
06) Yes No
07) Yes No
08) Yes No
09) Yes No
10) Yes No
11) Yes No
12) Yes No
13) Yes No
14) Yes No
15) Yes No

List Your Carriers
Carrier Rep Name Rep Phone No. Rep E-Mail
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Other Carriers

Special Agency Information

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For More Information

If you would like to receive additional information on Insurance Management Solutions (IMS) from Xanatek, please contact the sales office toll-free at 800-875-6033 or e-mail us at sales@xanatek.com.