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Company Membership (NEW)
  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

    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 your information below.
  2. (*Required)
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  1. Company Name(*Required)
    Please tell us your Company name.
  2. First Name(*Required)
    Please tell us your first name.
  3. Last Name(*Required)
    Please tell us your last name.
  4. Address(*Required)
    Please tell us your address.
  5. City(*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
    xxx-xxx-xxxx
  9. Cell Phone
    Please enter a valid phone number
    xxx-xxx-xxxx
  10. Fax Number
    Please enter a valid fax number.
    xxx-xxx-xxxx
  11. Email(*Required)
    Please enter a valid email address.
  12. Website
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  13. Company President/CEO
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  14. Please provide a one sentence describing your company, service or product to be listed in the PIA's Company Diirectory
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  1. List 3 individuals and addresses (if different from above) to receive PIA mailings & magazine
  2. First Magazine Recipient
  3. Full Name
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  4. Position
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  5. Address
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  6. City
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  7. State
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  8. Zip Code
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  9. Phone
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    Format: 555-555-5555
  10. Email
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  11. Second Magazine Recipient
  12. Full Name
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  13. Position
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  14. Address
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  15. City
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  16. State
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  17. Zip Code
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  18. Phone
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    Format: 555-555-5555
  19. Email
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  20. Third Magazine Recipient
  21. Full Name
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  22. Position
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  23. Address
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  24. City
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  25. State
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  26. Zip Code
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  27. Phone
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    Format: 555-555-5555
  28. Email
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  1. Payments to PIA are not deductible as charitable contributions for federal income tax purposes. However, they may be deductible under other provisions of the Internal Revenue Code as business expenses.
  2. Event
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  3. Amount Due
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  4. If the Amount Due box is empty, please use the "PREV" buttons to navigate back and select your membership status. If this is not done, you will receive an error when trying to process your payment.
  5. 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.
  6. Credit Card Number(*Required)
    Please enter a valid Credit Card Number
  7. Credit Card Expiration(*Required)
    Please enter your Expiration date as MMYY
    MUST BE IN THE FORMAT MMYY (no spaces or / )
  8. Billing Zip Code(*Required)
    Please enter a valid zip code.
  9. WARNING: Clicking "submit" more than once may result in multiple charges to your credit card.
    Your confirmation will be emailed within 24 hours.
  10. Your confirmation will be emailed within the next 24 hours.

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PIA Large

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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