Agent Membership - Annual Dues

Based on licensed staff in an independent agency. PIA Membership dues are designed to produce a minimum payment for smaller agencies and proportionally higher dues for larger agencies.

 
What is your Agency Name?

 
Who is the primary contact person?

 
What is your agency Street Address?

 
City?

 
County?

 
State?

 
Zip?

 
Please include your phone number.

 
Please include your website.

 
Please list your three leading carriers.

This, and the following information, will remain confidential but will greatly aid us in research and development of member products and services.To add a paragraph, press SHIFT+ENTER.
 
What is your Agencies Annual Premium Volume?

 
What is the commercial lines percentage?

 
What is the personal lines percentage?

 
L/H percentage?

 
E/O Carrier:

 
Expiration Date:

 
Do you have another branch location?

     
 
What is the street address of your other location?

 
City:

 
State:

 
Zip:

 
Phone number of second location:

 
Who from your agency would you like to list as Agent Members of the Association (ie. receive association benefits/discounts)?

 
What is your total licensed staff size? *

Please include yourself.

Thank you for submitting your application for 1 -2 Licensed Staff. We are excited have you as part of the PIA of TN.
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Thank you for submitting your application for 3-4 Licensed Staff. We are excited have you as part of the PIA of TN.
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Thank you for submitting your application for 5-6 Licensed Staff. We are excited have you as part of the PIA of TN.
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Thank you for submitting your application for greater than 6 Licensed Staff. We are excited have you as part of the PIA of TN.
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