AGENTSOFAMERICA.ORG
APPLICATION FOR FREE MEMBERSHIP
MEMBERSHIP IN AGENTSOFAMERICA.ORG IS OPEN TO ALL PROFESSIONAL SERVICES FIRMS OR PERSONS WHO ARE INTERESTED IN THE DEVELOPMENT, EDUCATION AND PROMOTION OF INSURANCE AGENTS AND BROKERS, INCLUDING LIFE AND HEALTH AGENTS. REGISTER USERS WILL BE ENTITLE TO DISCOUNTS TO ALL FUTURE EVENTS, SEMINARS AND PROGRAMS, INCLUDING ALL EDUCATIONAL MATERIAL DEVELOPED AND PROMOTED BY AGENTSOFAMERICA.ORG

SEE BELOW FULL DESCRIPTION OF BENEFITS

* Indicates required fields
1. Name of Individual
Contact First Name*
Contact Last Name*
Contact Title*	Mr.  Mrs.  Ms.
2. Name of Firm
Name of Company*
Address*
City*
State*	.................Select.............. Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada South Dakota New Hampshire New Mexico New Jersey New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Kentucky Rhode Island South Carolina Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming All States
Zip*
Phone*
Fax
E-mail address*
	(Please provide your company email address. Free email accounts such as Yahoo, Hotmail, Google, AOL, AIM, etc are not acceptable)
Web Site	http://
3. Please Select a Username and Password.
Please select a username*
Select a password*
Password (Re Enter) *
4. Agency Type*	................Select................ Captive Agent Independent Agent Insurance Broker Managing General Agent Other - Go to Question 7
5. Number of Unlicensed Employees *	.....Select.... 1 - 4 5 - 9 10 - 19 20 - 49 50 - 99 100+
6. Number of Licensed Employees *	.....Select.... 1 - 4 5 - 9 10 - 19 20 - 49 50 - 99 100+
7. If you are selecting an Affiliate Membership, please tell us your type of firm.	Insurance Company Law Firm Reinsurance Broker Insurance Consultant Other
TERMS OF SERVICE & USE
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