Agency Membership Application Join the PIA of Wisconsin Current Status New MemberExisting Member Agency Information Agency NameAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Agency TypeSole OwnerPartnershipCorporationLLCAnnual P&C Premium Volume$0 - $500,000$500,000 - $2,000,000$2,000,000 - $5,000,000$5,000,000 - $10,000,000More than $10,000,000Other AffiliationsAgency Management SystemE&O CarrierE&O Expiration Date Date Format: MM slash DD slash YYYY Top 3 P&C Companies - List in orderWhat is the primary concern in your agency today? Primary Contact Information The Primary Contact will receive a copy of the Wisconsin Professional Agent magazine and all mailings from PIA State and National. The primary contact has voting rights at PIA national meetings. Primary contact and all agency staff have voting rights at PIA of Wisconsin meetings. Name First Last Designations CIC CISR CRM CPIA ARM CPCU Email License StatusLicensed Owner/ProducerLicensed StaffUnlicensed StaffEmployment StatusFull-time - More than 30 hoursPart-time - 30 or fewer hoursGenderFemaleMaleMagazine SubscriptionYesNo Other Agency Personnel All agency personnel are considered members of the PIA of Wisconsin when attending a function where there is a member/non-member fee. Number of Additional Employees012345Employee #1Employee #1 First Last Designations CIC CISR CRM CPIA ARM CPCU Email License StatusLicensed Owner/ProducerLicensed StaffUnlicensed StaffEmployment StatusFull-time - More than 30 hoursPart-time - 30 or fewer hoursGenderFemaleMaleMagazine SubscriptionYesNoEmployee #2Employee #2 First Last Designations CIC CISR CRM CPIA ARM CPCU Email License StatusLicensed Owner/ProducerLicensed StaffUnlicensed StaffEmployment StatusFull-time - More than 30 hoursPart-time - 30 or fewer hoursGenderFemaleMaleMagazine SubscriptionYesNoEmployee #3Employee #3 First Last Designations CIC CISR CRM CPIA ARM CPCU Email License StatusLicensed Owner/ProducerLicensed StaffUnlicensed StaffEmployment StatusFull-time - More than 30 hoursPart-time - 30 or fewer hoursGenderFemaleMaleMagazine SubscriptionYesNoEmployee #4Employee #4 First Last Designations CIC CISR CRM CPIA ARM CPCU Email License StatusLicensed Owner/ProducerLicensed StaffUnlicensed StaffEmployment StatusFull-time - More than 30 hoursPart-time - 30 or fewer hoursGenderFemaleMaleMagazine SubscriptionYesNoEmployee #5Employee #5 First Last Designations CIC CISR CRM CPIA ARM CPCU Email License StatusLicensed Owner/ProducerLicensed StaffUnlicensed StaffEmployment StatusFull-time - More than 30 hoursPart-time - 30 or fewer hoursGenderFemaleMaleMagazine SubscriptionYesNoPayment Checkout The table below is used to calculate your membership cost. Your agency will be contacted by PIAW staff to complete the process. Agency SizeAmountAgency SizeAmount 1$38516$1,025 2$43017$1,070 3$47518$1,110 4$52019$1,155 5$56520$1,185 6$60521$1,230 7$65522$1,270 8$69523$1,320 9$73524$1,360 10$77525$1,405 11$82026$1,445 12$86527$1,490 13$90028$1,530 14$94029$1,575 15$98530 & Over$1,610 Payments to PIA are not deductible as charitable contributions for federal income tax purposes. However, they may be deductible under the provisions of the Internal Revenue Code as a business expense. This iframe contains the logic required to handle Ajax powered Gravity Forms.
