Independent Insurance Agents & Brokers of Louisiana

* First Name
* Last Name
Name on badge
Date of birth (mm/dd/yyyy)
* Email
* Address Line 1
* City
* State
* Zip
* Agency or Business Name
Daytime Phone
Guest Name

Input fields with an asterisk (*) are required.

I agree that by registering for this Event, I will allow the information that I have provided in this registration form (excluding financial and disability information) as well as my image or likeness to be reproduced by IIABA or the sponsoring state association ("Sponsor") in any media, including, for example, electronic or print form, for use on web sites, or in any other publications, promotions, or presentations created by the Sponsor, in the Sponsor's sole discretion.

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IIABR January Installation Luncheon