Independent Insurance Agents' Association of Montana

Independent Insurance Agents' Association of Montana
Agency Member Application for July 1, 2026 - June 30, 2027

Renewal Due July 1, 2026
Agency Name:*
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Street Address Same as Mailing Address*

YesNo
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact:*
Phone:*
Format: (000) 000-0000.
Agency FEIN/Tax ID:
Email:*
example@example.com
Website:
Dues Calculation:
Employee Definition: IIAMT dues are based on the total number of persons working in the property & casualty insurance business for your agency twenty (20) or more hours per week. This includes those working in an insurance capacity as stakeholders, partners, individual proprietors, licensed persons, and all other employees who work for your agency as stated above.
If more than 16 employees, please use this formula: $3,000 + ($16 x the number of total employees) = Total Annual Dues. Dues are capped at $6,000.
Include with your application - Upload Documents below

E&O dec pageAgency LicenseProducer LicensesW-9Completed EFT Authorization Form (new members only - for commission payments)
Access the EFT Authorization Form HERE.
Include with your application - Upload Documents below OR complete page 2 and 3 of this form

Employee RosterBranch Locations (if applicable)
Upload Documents

Cancelof
TOTAL NUMBER OF EMPLOYEES:*
TOTAL DUES:*
I certify that the total number of employees is accurate, I have read the Trusted Choice License Agreement (available at www.trustedchoice.independentagent.com/tc-license-agreement/) and the Pledge of Performance (www.trustedchoice.com/about-us/pledge-of-performance).
Due Date: 7/1/2026
Credit Card: Click here to submit dues payment. Please return to this form and complete.

Check: Make checks payable to: IIAMT, 8354 Northfield Blvd, Suite 2710, Denver, CO 80238
Signature:*
Date:

MonthDayYear
Date
Dues include membership in the Independent Insurance Agents & Brokers of America. Dues to Independent Insurance Agents' Association of Montana are not deductible as a charitable contribution but may be deductible as an ordinary and necessary business expense. A portion of the dues, however, is not deductible as an ordinary and necessary business expense to the extent your Association engages in lobbying. This percentage will be available in February 2027.

Independent Insurance Agents' Association of Montana

Agency/Company Roster
Please complete the agency roster below. If you have the roster in a different file format, you can send that to us separately or upload on the previous page.

Agency/Company Roster

Rows	Name	Title	Email
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Independent Insurance Agents' Association of Montana

Branch Locations
Please provide branch location details below, if applicable. If you have this information in a different file format, you can send that to us separately or upload on the previous page.
Branch 1:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Branch 2:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Branch 3:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Branch 4:
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Main Contact:
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Should be Empty:

Independent Insurance Agents' Association of Montana

Agency Member Application for July 1, 2026 - June 30, 2027

Dues Calculation:

Independent Insurance Agents' Association of Montana

Independent Insurance Agents' Association of Montana