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PIA Agency Membership (RENEWAL)
  1. Professional Insurance Agents of Wisconsin, Inc.
    6401 Odana Road
    Madison, WI 53719
    608-274-8188 | 800-261-7429 | Fax 608-274-8195
    www.piaw.org

    Affiliations, Franchises, & Clusters: Each individual agency shall join separately.
    Online registration is only available with credit card payment. Pre-payment is required. Registration without payment will not be processed.
    PIAW now accepts the following major credit cards:
    mastercard 48visa 48amex 48discover 48
    Payments are securely processed through Payment Service Network.
  1. Please enter information for your MAIN location below. If you have multiple locations you can enter them on the following pages.
  2. Agency Application Type(*Required)
    Invalid Input
  3. Agency Name(*Required)
    Please tell us your Company or Agency name.
  4. Address(*Required)
    Please tell us your address.
  5. City6(*Required)
    Please tell us your city.
  6. State(*Required)
    Please tell us your state.
  7. Zip Code(*Required)
    Please enter a valid zip code.
  8. Phone(*Required)
    Please enter a valid phone number
    Format: xxx-xxx-xxxx
  9. Fax Number
    Please enter a valid fax number.
    Format: xxx-xxx-xxxx
  10. Email(*Required)
    Please enter a valid email address.
  11. Website
    Invalid Input
  1. Please enter information for your SECOND location below.
  2. Agency Name
    Please tell us your Company or Agency name.
  3. Address0
    Please tell us your address.
  4. City3
    Please tell us your city.
  5. State2
    Please tell us your state.
  6. Zip Code
    Please enter a valid zip code.
  7. Email
    Please enter a valid email address.
  8. Phone
    Please enter a valid phone number
    Format: xxx-xxx-xxxx
  9. Fax Number
    Please enter a valid fax number.
    Format: xxx-xxx-xxxx
  10. Website
    Invalid Input
  1. Please enter information for your THIRD location below.
  2. Agency Name
    Please tell us your Company or Agency name.
  3. Address2
    Please tell us your address.
  4. City1
    Please tell us your city.
  5. State7
    Please tell us your state.
  6. Zip Code
    Please enter a valid zip code.
  7. Email
    Please enter a valid email address.
  8. Phone
    Please enter a valid phone number
    Format: xxx-xxx-xxxx
  9. Fax Number
    Please enter a valid fax number.
    Format: xxx-xxx-xxxx
  10. Website
    Invalid Input
  1. Additional Locations
  2. NOTE: If you have more than 3 (three) additional locations to add, please do not enter them in this form. Please send a list via email to Becca Prestbroten at bprestbroten@piaw.org or use the upload feature below to upload a Word or Excel document with your application
  3. Additional Locations List
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  1. The primary contact will receive a copy of the Wisconsin Professional Agent magazine and mailings from PIA State and National.

    The Primary contact will have voting privileges at both PIA State and National.
  2. First Name
    Please tell us your Company or Agency name.
  3. Last Name
    Please tell us your address.
  4. Designations
    Please tell us your city.
  5. National Producer #
  6. Cell Phone
    Please enter a valid phone number
    Format: xxx-xxx-xxxx
  7. Date of Birth
    Invalid Input
    Format: mm/dd/yyyy
  8. Gender
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  9. Employment Status
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  10. Full or Part Time?
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  1. Please enter your agency information below.
  2. Agency Type
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  3. Other Associations affiliated with
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  4. Top 3 P&C Companies (list in order)
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  5. What is the primary concern in your agency today?
    Invalid Input

  6. E&O Carrier
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  7. Expiration Date
    Invalid Input
    Format: mm/dd/yyyy

  8. Annual P&C Premium Volume
    Invalid Input
  9. Name of Agency Management System
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  1. Additional Staff Information
  2. NOTE: If you have more than 10 (ten) additional employees to add, please do not enter them in this form. Please send a list via email to Becca Prestbroten at bprestbroten@piaw.org or use the upload feature below to upload a Word or Excel document with your application
  3. Additional Employees List
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  1. Additional Staff #1

    If you do not have more additional staff, please scroll down and click the next button.
  2. First Name
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  3. Last Name
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  4. Designations
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  5. Email
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  6. Date of Birth
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    Format: mm/dd/yyyy
  7. Location
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  8. Gender
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  9. Employment Status
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  10. Full or Part Time?
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  11. Additional Staff #2
  12. First Name
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  13. Last Name
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  14. Designations
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  15. Email
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  16. Date of Birth
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    Format: mm/dd/yyyy
  17. Location
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  18. Gender
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  19. Employment Status
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  20. Full or Part Time?
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  21. Additional Staff #3
  22. First Name
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  23. Last Name
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  24. Designations
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  25. Email
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  26. Date of Birth
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    Format: mm/dd/yyyy
  27. Location
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  28. Gender
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  29. Employment Status
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  30. Full or Part Time?
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  31. Additional Staff #4
  32. First Name
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  33. Last Name
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  34. Designations
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  35. Email
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  36. Date of Birth
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    Format: mm/dd/yyyy
  37. Location
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  38. Gender
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  39. Employment Status
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  40. Full or Part Time?
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  41. Additional Staff #5
  42. First Name
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  43. Last Name
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  44. Designations
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  45. Email
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  46. Date of Birth
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    Format: mm/dd/yyyy
  47. Location
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  48. Gender
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  49. Employment Status
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  50. Full or Part Time?
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  1. Additional Staff #6

    If you do not have more additional staff, please scroll down and click the next button.
  2. First Name
    Invalid Input
  3. Last Name
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  4. Designations
    Invalid Input
  5. Email
    Invalid Input
  6. Date of Birth
    Invalid Input
    Format: mm/dd/yyyy
  7. Location
    Invalid Input
  8. Gender
    Invalid Input
  9. Employment Status
    Invalid Input
  10. Full or Part Time?
    Invalid Input
  11. Additional Staff #7
  12. First Name
    Invalid Input
  13. Last Name
    Invalid Input
  14. Designations
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  15. Email
    Invalid Input
  16. Date of Birth
    Invalid Input
    Format: mm/dd/yyyy
  17. Location
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  18. Gender
    Invalid Input
  19. Employment Status
    Invalid Input
  20. Full or Part Time?
    Invalid Input
  21. Additional Staff #8
  22. First Name
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  23. Last Name
    Invalid Input
  24. Designations
    Invalid Input
  25. Email
    Invalid Input
  26. Date of Birth
    Invalid Input
    Format: mm/dd/yyyy
  27. Location
    Invalid Input
  28. Gender
    Invalid Input
  29. Employment Status
    Invalid Input
  30. Full or Part Time?
    Invalid Input
  31. Additional Staff #9
  32. First Name
    Invalid Input
  33. Last Name
    Invalid Input
  34. Designations
    Invalid Input
  35. Email
    Invalid Input
  36. Date of Birth
    Invalid Input
    Format: mm/dd/yyyy
  37. Location
    Invalid Input
  38. Gender
    Invalid Input
  39. Employment Status
    Invalid Input
  40. Full or Part Time?
    Invalid Input
  41. Additional Staff #10
  42. First Name
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  43. Last Name
    Invalid Input
  44. Designations
    Invalid Input
  45. Email
    Invalid Input
  46. Date of Birth
    Invalid Input
    Format: mm/dd/yyyy
  47. Location
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  48. Gender
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  49. Employment Status
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  50. Full or Part Time?
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  1. Calculate Membership Amount Due

    Part-time employees count as one-half. If count ends in half, drop half.
  2. # Owners
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  3. # Producers
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  4. # Licensed Staff
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  5. # Unlicensed Staff
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  6. Total Agency Size
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  7. Number of Staff calculated above. (Remember to round down to the neraest whole number)
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  1. By clicking here, you undersatnd and agree to our terms and conditions.(*Required)

    Please check to verify that you have read and agree to the terms listed.
  1. Amount Due
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  2. WARNING: Your amount due is automatically calculated. If your Amount Due does not contain a dollar amount, please use the "Prev" button at the bottom of the form to go back TWO pages and be sure you have selected a "Number of Staff calculated above" at the bottom of that page.
  3. Event
    Invalid Input
  4. Please enter your payment information below.

    PIAW now accepts the following major credit cards:
    mastercard 48visa 48amex 48discover 48
    Payments are securely processed through Payment Service Network.

  5. Credit Card Number(*Required)
    Please enter a valid Credit Card Number
  6. Credit Card Expiration(*Required)
    Please enter your Expiration date as MMYY
    MUST BE IN THE FORMAT MMYY (no spaces or / )
  7. Billing Zip Code(*Required)
    Please enter a valid zip code.
  8. WARNING: It may take a few moments to process your payment. Clicking "submit" more than once may result in multiple charges to your credit card. If you are not redirected after submitting your payment, please call the PIAW at 608-274-8188
    Your confirmation will be emailed within 24 hours.

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Professional Insurance Agents of Wisconsin
6401 Odana Road | Madison, WI 53719
Phone: (608) 274-8188 | Toll Free (800) 261-7429
Fax: (608) 274-8195 | Toll Free (866) 203-7461

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