Associate Application


	Associate Member Application


	Company Name:


	Head office:


	Branch Office:


	Contact First Name:


	Contact Last Name:


	Mailing Address:


	City:

	Zip Code:

	Street Address:

	City:

	Zip Code:

	Phone:

	Fax:

	Email:

	Website:


	State:


	State:


	Choose your login & password - 10 characters - letters & numbers only - no spaces


	Login:

	Password:


	*Make sure to write these down in a secure place for future reference - you will need them to be able to access the PIAWest.com membership section of the website.*


	To help us serve you better and give you the type of exposure most suitable for your needs complete the following.


	For insurance carriers - select all that apply:

	Personal Lines
	Commercial Lines
	Home
	Auto
	Surplus
	Non-Standard


	Other information about the lines you cover: Niche Markets Covered:




	For others check all that apply:

Service:		type:
Product:		type:
Other:
Automation, Computers, software:
Agency Management:
Financial Management:
Marketing:
Broker:


	Please provide a contact name and number for agency members who would like to do business with you:

	Contact 1	Contact 2
First:
Last:
Phone:
Email:

Please provide a detailed description of your business, products, services, etc. This is for a catalog with associates member benefits to our agency members, and is updated twice yearly. It may also be used in upcoming newsletter articles.




	Company Description:


	Include a description of any special discount, benefit, report or freebie that you will be offering members:


	Are you interested in providing an educational class or workshop sponsored by PIA?


	Yes


	No


	Are you currently appointing new agents?


	Yes


	No


	Can you provide meeting space for PIA meetings or classes?


	Yes


	No


	Please Comment: What else can you offer members? What exposure opportunities can PIA provide for you?


	Which states are you currently active in?

Alaska	Idaho	Nevada
Arizona	Montana	Oregon
California	New Mexico	Washington

	Oregon/Idaho - $377.00
	Washington/Alaska - $377.00
	Montana - $200.00
	Group (CA, AZ, NM, NV) - $300.00


	Join any two chapters = 15% discount Join any three chapters = 20% discount Join any four chapters = 25% discount

Please Note: Membership is for one year beginning and ending in the month that we receive your first payment

** Membership includes Main Street Journal (a $12.00 Value)

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