Thank you for your interest in joining IIAT!

Please completely fill out the Membership Application.

We will review your application and will follow up with a membership invoice pending approval.

Please note the membership process takes about 2-3 days.

For questions, please contact Rae Mock at rmock@iiat.org.

Agency Information
- Entity Legal Name *
  
  Agency DBA Name
- Telephone (format as example: 555-555-5555) *
  
  Website
Primary Address (Mailing)
- Street 1 *
  
  Street 2
  
  City *
- County *
  
  State *
  
  Zip Code *
Secondary Address (Physical)
- Address2 Street 1
  
  Address2 Street 2
  
  Address2 City
- Address2 County
  
  Address2 State
  
  Address2 Zip Code
Staff Size
- Please provide the number of full time employees within your agency (please include all principals/owners/shareholders and all locations). *
Primary Contact (This role is able to update your company's information, employee listing (add, edit, transfer, remove), and pay company invoices - including membership dues. *This is who the membership dues are addressed to.)
- Primary Contact First Name *
  
  Primary Contact Last Name *
  
  Primary Contact Phone (format as example: 555-555-5555) *
- Primary Contact Email *
  
  Primary Contact TDI Number
  
  Primary Contact NPN
- Primary Contact Title
  
  Primary Contact Role
  
  select
  
  Account Manager
  Business Vendor/Partner
  Claims Manager
  Communication/Marketing
  Customer Service Representative
  Educator
  Finance and Accounting
  Leadership/Management
  Other
  Principal
  Producer
  Sales Manager
  Student
  Underwriter
Agency Owner/Principal (This role has all the same functions as the Primary Contact and has access to Principal's only content.)
- Owner/Principal same as Primary Contact
- Agency Owner First Name
  
  Agency Owner Last Name
  
  Agency Owner Phone (format as example: 555-555-5555)
- Agency Owner Email
  
  Agency Owner TDI Number
  
  Agency Owner NPN
- Agency Owner Title
  
  Agency Owner Role
  
  select
  
  Account Manager
  Business Vendor/Partner
  Claims Manager
  Communication/Marketing
  Customer Service Representative
  Educator
  Finance and Accounting
  Leadership/Management
  Other
  Principal
  Producer
  Sales Manager
  Student
  Underwriter

Demographics

Carry E&O Insurance?

E&O Premium

E&O Expiration

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E&O Carrier

Approximate Percentage of your Annual Revenue
- Percent Personal Lines
  
  Percent Commercial Lines
  
  Percent Life & Health
Type of Business Entity
- Business Entity
  
  What type of agency are you?
  
  Size of Agency Revenue
- Years Experience
  
  In Business Since (Year)
  
  Are you affiliated with an aggregator/networks/alliances?
- Join Reason
  
  Other Join Reasons
We certify that the information provided above is true and correct and that we have read the eligibility requirements and do qualify as an independent insurance agency as outlined.
We agree to observe the bylaws and ruled of IIAT and to pay dues based on our agency personnel lead count at all locations as of the date of this application. Failure to report accurate head count at all locationscould cause IIAT to decline your application. We understand that in case of any questions concerning the head count, the IIAT board of directors reserves the right of verification.
Please allow 2-3 business days for review of your membership application.
I hereby submit this completed IIAT Agency membership application.

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Agency Membership Application

Thank you for your interest in joining IIAT!

Please completely fill out the Membership Application.

We will review your application and will follow up with a membership invoice pending approval.

Please note the membership process takes about 2-3 days.

For questions, please contact Rae Mock at rmock@iiat.org.

I hereby submit this completed IIAT Agency membership application.