Independent Insurance Agents of Georgia, Inc.
Independent Insurance Agents of Georgia, Inc.
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IIAG Membership Application  

  
 
* Agency or Business Name
* AGENCY License #
* Number of Agency and Branch Personnel (Include owners/managers, producers, exclusive independent contractors, and all support staff.
* First Name
* Last Name
Designations
* Email
License #
Person 2 Name, Title, License#, Email Address, Birthday Year
Person 3 Name, Title, License# , Email Address, Birthday Year
Person 4 Name, Title, License# , Email Address, Birthday Year
Person 5 Name, Title, License# , Email Address, Birthday Year
Person 6 Name, Title, License# , Email Address, Birthday Year
Person 7 Name, Title, License# , Email Address, Birthday Year
* Year Agency Was Established
* Address Line 1
Address Line 2
* City
* County
* State
* Zip
* Daytime Phone
I need agency E&O Insurance program Information: Yes or No
Fax
Web Address
* List Your Agency's Company Appointments
Additional Agency Appointments
* Percentage of business written directly with insureds: %
* Percentage of business brokered from other agents %
* List one. My agency is this type of entity: 1)Corporation 2) Partnership 3) Sole Propietorship 4)Other
Agency E & O insurance carried by:
Expiration Date of E&O Policy?
% of personal lines business
Do you need additional markets?
Do you need Premium Financing?
Do you need an E&O quote?
Are you a member of any other insurance professional trade organizations? Example (NIA, PIA, Big ā€œIā€ in another state) YES/NO
Please list the insurance organizations you belong to and in which state
Does your agency use Social Media, like Facebook, LinkedIn, Twitter, etc.?
Input fields with an asterisk (*) are required.

 
 
BuyQtyDescription
Apply for IIAG Membership
I agree that this application for membership is subject to the approval of the District Director in the area which my agency is located. I hereby certify the information contained in this application is true and correct. I authorize the Independent Insurance Agents of Georgia and/or its agents to verify any of the information contained in this application.