Empower Agent Life Case Referral


    Fill out the form below. An Empower agent will contact your referral to give them fast and friendly service.
    We will provide a status to you along the way.

  • When we receive your referral and an agent has been assigned.

  • After we contact the client.

  • Bi-weekly until the sales cycle is finished.

  • We recommend keeping in touch with your referral to offer your continued support and to ask for referrals.

    Referral Information

    Client Name(s) (required)





    Additional Notes

    Sales Agent Name

    Agent Email

    Agent Phone


    By checking this box, you consent to receive text messages from Empower Brokerage and/or a licensed Empower Brokerage agent. These messages may include marketing messages (e.g., promotions, reminders) and follow-up communications related to your inquiry to the number provided, which may include the use of an autodialer. Message and data rates may apply. Message frequency varies. You can unsubscribe at any time by replying STOP or clicking the unsubscribe link.

    By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. By clicking and submitting this form, I understand that I am enrolling in an ongoing marketing campaign about insurance services and other options from Empower Brokerage or a licensed agent, and I will receive phone calls and e-mails (even if that phone number is on any Do Not Call Registry or is a mobile number). If you want to opt out of receiving future e-mails from Empower Brokerage, you can do so at any time by clicking the “unsubscribe” button in our e-mail. For more details, see our Privacy Policy.