2026 MOMENTUM MAKER AWARD CLAIM

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2026 VIP Momentum Maker Award Contest CLAIM FORM!

Accelerate Your Success!

When a Partner or Managing Partner opens their 3rd Assurity Case in 2026, regardless of case size,they will receive the AMAZING "Momentum Maker 2026" Custom Technical Trucker Cap!

This high-performance hat is made by BOCO Gear, the best in the business for top endurance athletes.

RepMove Mobile CRM Bonus!
Not only will you get this cool swag, BUT VIP will also pay for the remainder of your RepMove Mobile CRM Account for 2026 if you are already enrolled! You must already be enrolled in RepMove and be an active user of this technology.

Let's go get these cases, add to your book of business, add to your financial future, and make
momentum!
Terms and conditions apply. Contact Britton Johnson for more details.
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TODAY'S DATE
Date
Month
Day
Year
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Partner's Name
First Name
Last Name
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Who is your Executive Partner Team - They will receive a notification email that you are crushing it!* This field is required.
THE RHYTHM - Alfred and Karen Rietkerk
TEAM POWERHOUSE - Susan Svarda
TEAM TRAILBLAZERS - Zach Milwood and Rick McKinney
TEAM CHIEF - Alex Sell and Treve Rasmussen
TEAM BAD AZ - Denise Forconi
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New Cases Verification - Please List the 3 New Assurity Cases that you have Transmitted. There is no Policy Count Qualification* This field is required.
Assurity Group #1
Assurity Group #2?
Assurity Group #3
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Your VIP Email so you have a receipts of this. You will want to save this for your records. This can add up to BIG bonuses this year.* This field is required.Typing in the incorrect address will result in a loss of records for you.
jdoe@voluntarypartners.com
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Phone Number* This field is required.
Area Code
Phone Number
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Shipping Address for your BOCO Gear Cap! * This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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ARE YOU CURRENTLY A REPMOVE CLIENT?* This field is required.
YES! Thanks for covering my costs for 2026!
I am not currently a RepMove user and I have been with VIP for 6 months or more
I am not a RepMove User, and I have been with VIP for LESS than 6 months
I don't think I would use this tool. Let's not waste resources.
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{partnersName} PLEASE READ COMPLETELY

Integrity Statement & Partner Acknowledgement

Statement of Truthful Reporting:

By submitting these figures, I hereby certify that all information provided is accurate, truthful, and derived directly from my transmittals that were sent in to Assurity by myself or my Enrollment Director.

Data Validation & Matching:

I acknowledge that I fully understand how to properly filter and compare the matching dates within our reports to ensure the data aligns with the required reporting period. I have verified that the policy counts reported correspond strictly to the transmitted business within the specified timeframe.

Consequences of Misrepresentation:

I understand that any intentional misrepresentation, inflation, or falsification of production data is strictly prohibited and is considered contest manipulation. I acknowledge that such actions are a breach of professional integrity and will result in:

Immediate termination of my Partnership with VIP.

Termination of Appointments with all associated insurance carriers

Acknowledgement
By signing below , I confirm that I have read the previous statement and that my production submission is an honest reflection of my Transmittals
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Acknowledgement
Clear
Should be Empty: