PIANEIA - Join Today! Agency Membership Application

Membership in PIA is an invaluable tool to help you succeed in the insurance industry. To join online with a credit card or check, simply fill out the form below. If you would prefer to join via mail, please use the printable form.

Name of Agency:

Mailing Address:

PO Box:

City:

State:

Zip Code:

Country:

Phone Number:

Fax Number:

Email Address:

Website Address:

Name and Designations:

Date of Birth (i.e. 05/05/1965):

Gender:

Employment Status:

Part-Time:

Agency Information

Agency type:

Associations affiliated with:

Top 3 P&C Companies (list in order):

1:

2:

3:

Which Agency Management System are you using?:

E&O Carrier:

Expiration Date (i.e. 05/05/2005):

Annual P&C Premium Volume:

Payment Information (Part-time employees count as one-half. If count ends in half, drop half.):

Total Agency Size:

To pay by credit card, please call (402) 392-1611.

To pay by check, please send your payment to:

PIA Association for Nebraska & Iowa
920 South 107th Ave, Ste 305
Omaha, NE 68114

Checks for dues should be made payable to:

PIA of Nebraska

Dues Schedule: