IMCA Supporting Member Application
Organization Name
*
Please list the company name as you want it shown on publicly on the IMCA website.
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company logo (to be used on IMCA website and marketing materials)
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Who will your company administrator for IMCA be? (primary point of contact for your membership for payments and roster updates)
*
First Name
Last Name
Company administrator email
*
example@example.com
Company administrator title
*
Individual Information for Company Roster (enter N/A in all empty fields to submit)
*
Please provide a description of your company (Type of business, primary customer type in the insurance marketing industry, products and services relevant to insurance marketers, focus on certain insurance lines, etc.). This description will be used on the IMCA website to convey information about your company to fellow members.
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