Agency Membership Application

Agency Membership Application

Main Office Location
Agency Name
Principal Contact

First Name Last Name
Email
example@example.com
Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number

Mailing Address (if different from Street Address)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

If you do not have any branch locations, please click "NEXT"

Branch Location
Branch Name
Branch Main Contact

First Name Last Name
Email
example@example.com
Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number

Employees at Branch Location

	Principal, Producer, or CSR	Name	E-mail	Licensed?
1
2
3
4
5
6
7
8
9
10

Additional Branch Location
Branch Name
Branch Main Contact

First Name Last Name
Email
example@example.com
Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number

Employees at Branch Location

	Principal, Producer, or CSR	Name	E-mail	Licensed?
1
2
3
4
5
6
7
8
9
10

Additional Branch Location
Branch Name
Branch Main Contact

First Name Last Name
Email
example@example.com
Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number

Employees at Branch Location

	Principal, Producer, or CSR	Name	E-mail	Licensed?
1
2
3
4
5
6
7
8
9
10

Additional Branch Location
Branch Name
Branch Main Contact

First Name Last Name
Email
example@example.com
Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number

Employees at Branch Location

	Principal, Producer, or CSR	Name	E-mail	Licensed?
1
2
3
4
5
6
7
8
9
10

Additional Branch Location
Branch Name
Branch Main Contact

First Name Last Name
Email
example@example.com
Street Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number

Employees at Branch Location

	Principal, Producer, or CSR	Name	E-mail	Licensed?
1
2
3
4
5
6
7
8
9
10

Companies Represented (with which you have a direct relationship)

Here at the Big "I", we are constantly looking for ways to help you and your employees prosper. We value your membership and hope to continue providing products and services that meet or exceed your needs. What are the areas that interest you most?

Insurance MarketsContinuing EducationProfessional DevelopmentE&O CoverageNetworking EventsLicensing PrepAdvocacyBranding Your Agency

When invoiced, would you prefer to pay:

AnnuallySemi-annuallyQuarterly
(Please note, there are no additional fees with scheduled payments)
Application is hereby made for membership (or continued membership) in the Independent Insurance Agents of New Mexico, Inc. I agree to observe the bylaws and policies of the Association and pay dues based on the total number of employees in my agency. All branches will be reported and the appropriate dues paid. I certify that I meet all membership requirements of the Association and that the information contained in this application is true and correct.

It is understood that new members must be approved by the board of the Association.
Signature

Clear
Date

MonthDay Year
Date
Should be Empty: