First Name:

Last Name:

Company Name

Company Mailing Address:

City:

State:

Zip:

Company Physical Address:

City:

State:

Zip:

Phone:

FAX:

Email Address:

Oregon/Idaho Affiliate Chapter Membership**

$1500.00

Washington/Alaska Affiliate Chapter Membership**

$1200.00

Discounted Membership for both Affiliate Chapters**

$2400.00

Associated PIA Western Alliance Membership $377 Value**

FREE

For Insurance Carriers - check all that apply

Niche Markets Covered

Personal Lines

a.

Home

b.

Auto

For other types of companies -

Commercial Lines

check all that apply:

Surplus

Service type:

Non-Standard

Product type:

Other Information about the Lines you

Automation, computers, software

cover:

agency management

a.

financial management

b.

marketing

broker

other

First Name:

Last Name:

Phone:

First Name:

Last Name:

Phone:

Yes

No

Are you currently appointing new agents?

Yes

No

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

Yes

No

Can you provide meeting space for PIA meetings or classes?

Alaska

Idaho

Nevada

Arizona

Montana

Oregon

California

New Mexico

Washington