InsureWomen Founding Member Application

Founding Member Application

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has." Margaret Mead
Full Name*

First NameLast Name
E-mail*
Company Name*
Company Website *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Are you a licensed insurance agent?*

YESNO
What types of Insurance do you sell?*

Property & Casualty (Auto, Home, Umbrella, etc)Commercial/BusinessLife InsuranceLong Term CareEmployee BenefitsDisabilityOther
Are you an independent or captive agent?

IndependentCaptive
Please share any insurance designations you have (i.e. CIC, CLU, etc.).
How does your company provide value to/support female insurance agents?*
As an InsureWomen Founding Member, we expect you to abide by a Code of Honor which reflects a character of respectfulness, honesty and a commitment to female agents and women purchasing insurance. Please read the Code of Honor and sign if you agree.

The InsureWomen Code of Honor*
- I will treat all prospects and clients with the respect and attention they deserve
- I will encourage and uplift fellow InsureWomen
- I will present a work ethic of honesty and integrity
- I am committed to personal development and education
- I will educate and empower women in the insurance buying process
* If you are not an agent but represent a business that supports female agents, please sign to reflect your agreement.
Please sign here to acknowledge your agreement of the InsureWomen Code of Honor:*

Clear
Now for the fun stuff!

We want to promote you on the InsureWomen website and social media!
Please upload your headshot for us.*

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Please share your social media links with us!
LinkedIn   (Will link to your name on your InsureWomen website listing)
Facebook
Instagram
Other
Time to celebrate! We'd like to know the month and day you were born!
Month/Day
Did someone refer you to InsureWomen? We'd like to say thanks! Please let us know their name and email.
First Name Last Name
Email
Founding Member Options:
🙋🏻‍♀️ LICENSED INSURANCE AGENT MEMBERSHIP
💪 STAKEHOLDER MEMBERSHIP: You support InsureWomen's mission or your company serves female agents in some way
🎁 SPONSORED MEMBERSHIP If you would like to SPONSOR a Founding Membership for a fellow agent or a group of agents, please share their information in the form that follows.

Sponsored Memberships: Please fill out the form below so we can give them the good news!

	Name of Recipient	Email Address
1.
2.
3.
4.
5.

InsureWomen Founding Member Initiation Fee*

Founding Member Campaign Initiation Fee: Licensed Agent

$99.00

Founding Member Campaign Initiation Fee: Stakeholder Membership

$99.00

Founding Member Campaign Initiation Fee: Sponsor An Agent Product Image

Founding Member Campaign Initiation Fee: Sponsor An AgentWe will send a gift certificate to the recipient(s).

$99.00 Quantity

Total

$0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Should be Empty:

Founding Member Application

Now for the fun stuff!

Founding Member Options:

🙋🏻‍♀️ LICENSED INSURANCE AGENT MEMBERSHIP

💪 STAKEHOLDER MEMBERSHIP: You support InsureWomen's mission or your company serves female agents in some way

🎁 SPONSORED MEMBERSHIP If you would like to SPONSOR a Founding Membership for a fellow agent or a group of agents, please share their information in the form that follows.