Membership Application
Please fill out and submit this application and someone from the VIAA team will contact you shortly.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who referred you?
*
Give specific name or say internet search, email, etc.
Business Information
Agency Name
*
DBA:
How is your business filed:
*
Individual
LLC
INC
Other
FEIN:
Business Website
*
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this also your mailing address?
*
Yes
No
Mailing Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please tell us about your industry background and current situation.
*
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Current Experience
Are you currently part of a insurance network, cluster or aggregator?
*
Yes
No
What is the name of the insurance network, cluster or aggregator?
*
What Insurance Carriers has your current insurance network, cluster or aggregator appointed you with?
*
Please list all P&C Carriers you have written business with.
Do you currently have any direct carrier appointments that are NOT through a insurance network, cluster or aggregator?
*
Yes
No
Please list all P&C Carriers you have direct appointments with below, not associated with a insurance network, cluster or aggregator:
*
What is your niche and/or expertise if any?
Current Book of Business & Sales Goals
What was your Total Written P&C Premium in the last 12 Months?
*
How much NEW P&C premium do you anticipate writing in the next 12 months?
*
What is the total written P&C premium in your agency today?
*
Please check all of the lines your agency currently sells:
*
Personal
Commercial
Farm/Ranch
Life
Other
What is your total Personal lines premium in force:
*
What is your total Commercial lines premium in force:
*
What is your total Farm/Ranch premium in force:
*
Please explain other:
*
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Insurance Agency Systems & Technology
Do you currently have a agency management system dedicated to your insurance agency?
*
Yes
No
Other
Name of current management system:
*
Do you currently have a dedicated insurance CRM?
*
Yes
No
Other
Name of current CRM:
*
Do you currently have a Personal lines and/or Commercial Lines comparative rating system?
*
Yes
No
Other
What rating system(s) do you currently use:
*
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Background Questions
Have you or any Partner/Principal, filed for or been discharged from any bankruptcies, within the last 5 years?
*
Yes
No
Have you or any Partner/Principal, including current employees been prosecuted, fined, or placed on any corrective action by any State, Court, or Regulatory department?
*
Yes
No
Have you, any Partner/Principal, or current employee ever been convicted of a felony?
*
Yes
No
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