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141 London Parkway
Birmingham, AL 35211
Phone (205) 326-4129
Fax     (205) 326-3086
Copyright 2005
www.aiia.org
APPLICATION FOR AGENCY MEMBERSHIP
ALABAMA INDEPENDENT INSURANCE AGENTS, INC.
 

Thank you for your interest in the Alabama Independent Insurance Agents, Inc. Membership will entitle your organization to all member benefits as provided by the Association. Applicants must agree to abide by the Association Code of Ethics and By-laws, as well as Insurance statutes and regulations of the state of Alabama.

This application for Membership in the Alabama Independent Insurance Agents, Inc. is not binding until notification. All members must be approved by the Executive Committee.

Your AIIA Agency Membership includes membership with the National Trusted Choice(R) Brand. For more information about Trusted Choice, please visit their website here.

 

APPLICATION FORM
AGENCY NAME:

NAME OF CONTACT PERSON:

CORPORATE OFFICER OR PRINCIPAL:

ADDITIONAL PERSONNEL:

MAILING ADDRESS:

CITY:

STATE:

ZIP:

PHONE NUMBER:

FAX NUMBER:

EMAIL ADDRESS:

WEB DOMAIN NAME OR URL

FEDERAL TAX ID NUMBER

LIST THE PROPERTY & CASUALTY COMPANIES WITH WHICH YOU HOLD AGENCY CONTRACTS.
(You must have at least two.)

E&O CARRIER:

E&O EXP DATE:

NUMBER OF EMPLOYEES (For dues, please refer to the below table)
I would like information on the following AIIA member Only Programs:
Continuing Education 
Premium Financing 
Advertising with Logo Systems 
Errors & Omissions Coverage 
EPL Products 
Umbrella Products 
Upcoming Meetings 
Big I Markets Online Products and Markets
Trusted Choice(R)
Calculating Semi-Annual Dues


Number of  Employees

100 & over
50-99
30 - 49
23 - 29
17 - 22
14 - 16
13
12
11
10
9
8
7
6
5
4
1 - 3
 

Semi-Annual Dues

$1,373.00 
 $1,142.00 
 $1,089.00 
 $1,077.00 
 $   924.00 
 $   872.00 
 $   819.00 
 $   767.00 
 $   722.00 
 $   692.00 
 $   639.00 
 $   587.00 
 $   534.00 
 $   482.00 
 $   430.00 
 $   377.00 
 $   293.00
 

This is an application ONLY. Your membership must be approved by the Executive Committee and a review of the agency's company appointments. An AIIA staff member will contact your regarding membership approval and payment of the membership dues.


Thank You For Filling out this form!
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