PIAVADC / Smart Choice Membership App

PIA VA/DC - Agency Membership Application
Person Completing this Form*

First NameLast Name
Phone*
Email*
Billing Contact (Person to receive annual dues notice)*

Same As AboveDifferent Person
Billing Contact*

First NameLast Name
Phone*
Email*
(Pricing is shown on next page. Contact info above is required but is not saved if form is not submitted.)

Agency - An agency engaged in the insurance industry and is currently a Smart Choice Member. 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.

We do not offer individual memberships.

# of Full-Time P&C Agents	SMART CHOICE Price
1 - 2	$225.00
3 - 12	$330.00
13 - 19	$540.00
20 - 30	$627.50
31 +	$1,250.00

Select the # of Full-time, P&C Agents*

1 - 23 - 1213 - 1920 - 3031 +

List First Member Here
First member is typically the AGENCY PRINCIPAL.
First Name*
Middle
(or Mid. Initial)
Last Name*
Informal Name*
e.g.: Bob for Robert
Date of Birth*

MonthDayYear
Designations*
Enter none if not applicable.
Organization Name*
Street Address*
City*
State*
e.g.: VA
Zip*
Work Phone*
Cell Phone*
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, complete and email to membership@piavadc.com.

Other Information
Year Agency Started*
Website*
Current E&O Carrier*
E&O Expiration Month & Day*

I certify that the information on this application, including any attachments, is accurate and true. I give PIA permission to email, mail, or fax the people named above and in the attachments.*

Yes
Referred By
First & Last Name

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

To add more individuals, download this form, complete 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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PIA VA/DC - Agency Membership Application

Other Information