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AGENCY EXPERT Additional Modules Order Form – April 27, 2012 To place an order for Additional Modules for the AGENCY EXPERT, please complete this worksheet. Once completed, please FAX (303-449-0797 or 303-828-0588) or mail (with a method of payment properly defined or a check enclosed) to GBS, Inc. Your order will be processed and emailed to you the day we receive your request. If you should have any questions, please contact GBS, Inc. Sales Dept. at 800-231-8495 Ext. 505. GBS, Inc. Account Number:_______________ Please rush my AGENCY EXPERT Additional Modules to: Email Address: _________________ Name of Purchaser: ____________________________________ Phone Number (required): __________________________ Name of Agency: _______________________________________________ FAX Number: __________________________ Name of Contact (if different from Purchaser: ________________________________________________________________ Shipping Address (No P.O. Boxes Please): ___________________________________________________________________ City: __________________________________________ State: _____________ Zip Code: _____________ - __________ Enter your current version of AGENCY EXPERT: _____ Upgrade Agency Expert from ________version to _______ version. (Call for pricing) $ _________ Custom Screens Building Module $495 (+ add’l. $100/yr. Mandatory Support Fee) * $ _________ Laptop Sync. $199 (Internet Sync - $499) (Requires at least one add’l. Computer License at $50/yr. Mandatory Support Fee)* $ _________ MassFax $199 (+ Addtl. $50/yr Mandatory Support Fee)* $ _________ Mass Email $295 (+ Addtl. $50/yr Mandatory Support Fee – Note: Mass Email is included in MGA Version)* $ _________ Electronic (.PDF) Forms Module - $395 (+ Addtl. $200/yr Mandatory Support Fee)* $ _________ RFP Module - $295 (+ Addtl. $100/yr Mandatory Support Fee) $ _________ Network Efax $299 (Includes MassFax) (Requires that you have either an Efax or MyFax contract) $ _________ Network Fax Server 2003 $399 (Includes MassFax) (+ add’l. $50/yr. Mandatory Support Fee)* $ _________ Scan Module - Basic $295 (Requires a Twain compliant Scanner) (+ addtl. $50/yr. Mandatory Support Fee)* $ _________ Scan Module - Advanced $495 (Requires a Twain compliant Scanner w\ADF) (+ addtl. $50/yr. Mandatory Support Fee)* $ _________ Property / Casualty Module - $595 (+ add’l. $300/yr. Mandatory Support Fee)* - Includes ACORD Forms and Advanced Scanning $ _________ ACORD Forms - $300 (+ add’l. $250/yr. Mandatory Support Fee)* $ _________ Quickbooks Synchronization - $195 (+ add’l. $50/yr. Mandatory Support Fee)* $ _________ MS Outlook Synchronization. - $295 (+ add’l. 150/yr. Mandatory Support Fee)* $ _________ Multiple Database Module $495 (+ add’l. $200/yr./database Mandatory Support Fee)* $ _________ (One Database included, add’l. Database Licenses: $200/yr. Mandatory Support Fee each) NOT available with MSDE or SQL SQL Express "Back End" $495 (+ addtl. $200/yr. Mandatory Support Fee)* SQL "Back End" $995 (+ addtl. $500/yr. Mandatory Support Fee)* Web Reporting - $995 (+ add’l. $200/yr. Mandatory Support Fee)* Add’l Multi-User Licenses: $100 each (+ add’l $25/yr support)** for ____ Workstations * Add’l Computer Licenses: $50 each (+ add’l $50/yr support) for ____ Computers * Add’l Multi-Database Licenses: ( add’l $200/yr support) for ____ Databases * Terminal Services Licenses: $50/yr each (min of 2 licenses) for ____ Licenses * Access Database Unlock: $100 (+ add’l $100/yr Support Fee)* Replacement Install/Update Disc for Version ______ $25 for US Mail or $35 for Overnight = = = = = = $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ * Note: Support charges for any purchase that has an associated support fee are prorated. ** Note: + add’l $50/yr support for MGA version Colorado Residents must pay sales tax of 7.2% (Note: there is no sales tax on support services): Sub Total Sales Tax Shipping Charge Total Charge $ _________ $ __________ $ _________ $ _________ Desired Payment Mode: VISA MasterCard AMEX Discover Check Enclosed Card Number: __________________________________ Expires: _________ Credit Card Security Code #: ________ Credit Card Address (to which Statements are Mailed):___________________________________ Billing Zip Code: _________ REFUND NOTICE! The undersigned authorizes GBS, Inc. to charge the above card for the specified amount. Shipping, Data importing, Conversion charges and Renewal fees are NOT refundable. There is a charge for damaged or missing materials. ALL returns will be charged a $50 Restocking fee. To receive a refund, the purchased materials must be received by GBS no more than 60 days from the shipping date. This agreement shall be governed by Colorado Law and venue shall be proper in Boulder county, State of Colorado. Signature (Required): ________________________________________ , Title: _________________ Date: _______________ AddlModulesOrder.rtf (ADDL MODS ORDER)