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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.
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Mailing Addresses: |
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PO Box: |
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City: |
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| State: |
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Code: |
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County: |
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Phone Number: |
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| Fax
Number: |
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Email Address: |
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Website Address: |
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Primary Contact Information: |
The Primary Contact will receive a copy of the Nebraska "Reporter" magazine and all mailings from PIA State and National. The Primary
Contact will have voting privileges at both PIA State and National. |
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Name and Designations: |
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Date of Birth:
(i.e. 05/05/1965) |
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Gender: |
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Employment Status: |
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Part-Time: |
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Agency Information: |
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Agency type: |
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Associations affiliated with: |
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Top 3 P&C Companies (list in order): |
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1: |
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2: |
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3: |
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Which Agency Management System are you using? |
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E&O Carrier: |
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Expiration Date:
(i.e. 05/05/2005) |
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Annual P&C Premium Volume: |
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Payment Information: (Part-time employees count as one-half. If
count ends in half, drop half.) |
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Total Agency Size: |
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| Payment Type: |
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| Name as it appears on card: |
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| Credit Card Number: |
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| Card Expiration: |
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| To pay by check, please print form and mail
to:
PIA Association for Nebraska & Iowa
920 South 107th Ave, Ste 305
Omaha, NE 68114
Forms can also be faxed to 402-392-2228.
Checks for dues should be made payable to:
PIA of Nebraska
Return with check payable to:
PIA of Nebraska, 920 S 107 Ave, Suite 305, Omaha, NE 68114
PIAPAC
contributions are not deductible as charitable contributions
but may be allowable as a business expense. Consult your tax advisor on this.
Yes, I would like to support (PIAPAC) Nebraska Insurance
Political Action Committee and have enclosed
my personal check for $____________
Name: __________________________________________
Agency: _________________________________________
Address: _____________________________ City/State/Zip: _______________
Phone:_______________________________Fax:________________________
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