Influencers Insurance Application

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Lead Type

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GA Client ID

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Referral

First Name*

Last Name*

Email*

Phone*

Website (if any)

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Are you an Individual Influencer or Agency?*

Individual Influencer

Agency

Social Media Handles*

Platform

Profile URL

Followers

Click + to add multiple and provide follower count

Date of Birth

Annual Revenue*

Revenue from advertising on social media only.

Requested Insurance Limit*

Agency Name*

Annual Revenue*

Requested Insurance Limit*

Do you have a single view rate exceeding 1 million on a post you published on social media to date (we understand future posts may exceed 1 million views and/or go viral).

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Do you have a single view rate exceeding 1 million on a post you published on social media to date (we understand future posts may exceed 1 million views and/or go viral).

Yes

No

Please review the following statements and answer yes or no below:

You do not write, post or publish anything investigative or exposé.

You do not write, post or publish any religious or political content.

YYou do not own or host a social media network, website or platform that is primarily for others to post or publish their own content (we understand that you use social media platforms).

You are aware you cannot use content (such as images or music) that you did not create yourself without obtaining a licenses from the owner.

You always ensure to comply with the regulations and/or guidelines of each social network provider in relation to paid-for endorsements, maintaining transparency when your content is promoting a brand (eg: using #Ad on promotional Instagram posts).

You are aware of defamation, privacy & data security legislation and take a reasoned approach to your posted content

You may be involved in the promotion of tangible products, but not in their design, distribution, re-branding, re-packaging or sales..

You do not promote or endorse medications or surgical procedures.

You agree that you will remove anything that is the subject of a complaint within 48 hours of the complaint being received.

You do not expect that a failure of any of your products or services could result in any loss of life, injury to a person, destruction or damage to physical property.

I confirm the above statements are true and correct.

I confirm the above statements are true and correct.*

Yes

No

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