PIAVADC Membership Application

Membership Application
This application is for NEW memberships only. If your agency or company is currently a member, please email carol@piavadc.com to be added to the membership.
Person Completing this Form*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Email*
Same As AboveDifferent Person
Billing Contact*

First NameLast Name
Phone*
Format: (000) 000-0000.
Email*
(Pricing is shown on page 3. Contact info above is required but is not saved if form is not submitted.)

Membership Types
Agency - An agency engaged in the insurance industry. Agency membership receives all PIA of VA & DC benefits as well as PIA National. Agency membership dues is based on total number of full-time, P&C licensed agents. L&H or part-time agents need not be included in the total count.

Company - Officers, representative or employees of an insurance company/carrier or any other individual affiliated directly or indirectly with P&C or L&H insurance business. Annual dues are per company, not individual, and include an unlimited # of members. If you're looking to do more, we also have long-term sponsorship partners. Read more for details.

Associate - An organization that does not fall into either of the agency or company categories. Example: premium finance, service provider, etc. Annual dues are per company, not individual, and include an unlimited # of members.

Retired - An individual no longer in the insurance business but was an active member at one time. Must have been employeed by an organization that has been a PIA VA/DC member for at least three consectutive years.

Long-Term Sponsor Partners - Companies who gain additional benefits by locking in for a 3-year term.

NOTES
- Agencies less than three years old qualify for a "New Agency" discount. Contact membership@piavadc.com for more information.
- We do not offer individual memberships. You must fall into one of the above categories to qualify.

Membership Selection (choose one)*
prevnext( X )
Agency Membership
Select the total # of full-time, P&C licensed agents from the drop down menu below.

$450



Company Membership
$650



Associate Membership
$200



Retired Membership
$35



Diamond Long-Term Sponsor Partner
$10,000



Platinum Long-Term Sponsor Partner
$7,500



Gold Long-Term Sponsor Partner
$5,000



Silver Long-Term Sponsor Partner
$2,500

List First Member Here
(For AGENCY MEMBERSHIP - First member listed should be the AGENCY PRINCIPAL)
First Name*
Middle
(or Mid. Initial)
Last Name*
Informal Name*
e.g.: Bob for Robert
Date of Birth

MonthDayYear
Date
Designations*
Organization Name*
Street Address*
City*
State*
e.g.: VA
Zip*
Work Phone*
Format: (000) 000-0000.
Cell Phone*
Format: (000) 000-0000.
Email*
Resident State*
e.g. VA
Ins License #*
NPN*
ALL full-time, P&C agents must be submitted to PIA.

To add more individuals, download this form and email it to membership@piavadc.com.

Other Information

Applicable only to AGENCY Memberships; others may disregard.
Year Agency Started
Website
Current E&O Carrier
E&O Expiration Month & Day

Yes
Referred By
First & Last Name

Remember: ALL full-time, P&C agents MUST be submitted to PIA.

To add more individuals, download this form and email to membership@piavadc.com.

An invoice will be emailed within three business days to the person completing this form or billing contact provided. Payment is due upon receipt. To avoid delays, we recommend you pay online. Payment information will be included on the invoice.

Please note your form is not submitted until you press the SUBMIT button below.
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