Agency Membership Application PIA of Wisconsin Agency Membership Current Status New MembersExisting 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 Full-Time Employees01234567891011121314151617181920212223242526272829+Number of Additional Part-Time Employees01234567891011121314151617181920+Total Number of Employees for PricingTotal Number of Employees for Additional Employee Data FormEmployee #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 SubscriptionYesNo Employees Beyond Five If you would like to have additional employees receive our weekly PIA Newsline newsletter. Please attach a spreadsheet that includes their name and email address.Additional Employees UploadPayment Checkout The table below is used to calculate your membership cost. 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.Upon submission, a member of the PIAW team will reach out to discuss membership options and payment.Agency Membership Renewal* Price: $0.00 Total $0.00 Credit Card* Card Details Cardholder Name
