Fax Enrollment Form


____Yes, enroll me in your “Ultimate Insurance System”  Plus include all the bonus you mentioned in your report. By ordering our system you have read and understand our no risk 13-month Guarantee policy found in our sales letter.


Please Rush Me the “Ultimate Insurance System” at this special limited price.            

Great Deal! (__) Here’s 1 payment of $497 $397 (FREE Priority Mail S&H)


 Good Deal! (__) Bill my credit card in 4 installments of $121.00 (+$20 Priority Mail) Fax this form to


 (800) 397-3840 and receive additional $10.00 off the price.



access to our Free Trial offer “Annuity Pro Lead Capture Web Page and Auto Responder email system and monthly

client newsletter that can be personalized.” Set up fee for website of $495 is waived. After 30 days your

credit card will be billed for $39.00.  Normal charge is $59.00. You can cancel website and

client newsletter at anytime.

Need simple username extension for website like your first name or initials _____________ password ______________


Send My System To: (Please Print Clearly)


Name: ____________________________________ Phone: ___________________________________


Address: ___________________________________ EMAIL: _________________________________


City: _____________________ State: ______ Zip Code: _________ FAX:_________________________


Credit card Installment Plan: If you wish to pay in 4 equal installments, your credit card will be charged for the first installment

plus 3-Day Priority Shipping and Handling the day we ship your order.  The second installment will be charged 30 days later. 

The third installment will be charged 60 days later. The fourth installment 90 days later.  S&H is non-refundable.  Check payment: 

If you pay by check, please make payable to “Great Western Consulting LLC.” Personal Checks will be held for 5 days,

cashiers checks and money orders will be shipped immediately.  Thanks


Check or Money Order is enclosed


Credit Card Order: (__) Visa (__) Master Card (__) Discover (__) AMEX


Name of Card Holder (Please Print): _______________________________________________________________


Account Number: _____________________________________ Expiration Date: ______________


Authorized Signature: _____________________________________ Date: ____________________

CID# _________ (Last 3#’s on back of card for Visa, MasterCard, Discover. Last 4#’s on front of card for AMEX)


1)                         Call toll-Free: (800) 808-6551 to order

2)                         Send to: Great Western Consulting LLC., 550 East 100 South, Hyde Park, UT. 84318

3)               TOLL-FREE FAX To: (800) 397-3840