BrainShare Participant Registration Form

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Registration Type* This field is required. 🎟 General Admission — $699 For professionals attending BrainShare 2027 as a standalone event. If you are not registered for IndieTech 2027 and are not a member of the Agency Intelligence Champions Mastermind, this is your ticket. Full access to the entire day — breakfast, both mastermind sessions, lunch, and the private dinner on the evening of February 1st. 🎟 IndieTech Ticket Holder — $674 Exclusively for attendees who have already purchased — or are purchasing — a ticket to IndieTech 2027 (February 2–3, 2027) at the Hilton West Palm Beach. A discount code is required at checkout. 🎟 Mastermind Champion — $649 Exclusively for active members of the Agency Intelligence Champions Mastermind group. A discount code is required at checkout.
Please Select
Please Select
General Admission
IndieTech Ticket Holder
Mastermind Champion
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First Name* This field is required.
3
Last Name* This field is required.
4
City* This field is required.
5
State* This field is required.
Select your state
Select your state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Email* This field is required.
example@example.com
7
What is your role at the agency?* This field is required.
Please Select
Please Select
Agency owner / principal
Producer / agent
Operations / agency manager
Service / account manager
Carrier representative
Consultant / vendor
Other
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What is your agency's annual premium?* This field is required.
Example: $1,200,000.00
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What is your book of business mix? (Approximate percentages, must add to 100%)* This field is required.
%
Personal lines
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Commercial lines
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Life and health
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Benefits
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Other
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Personal lines
Commercial lines
Life and health
Benefits
Other
%
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%
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%
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%
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%
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Pick your top three topics you want to discuss at BrainShare.* This field is required.
Agency operations
Sales
Marketing
Hiring and firing
Buying and selling
Mergers and acquisitions
Agency Leadership
Agency Technology Adoption
11
What is the single biggest question you want answered at BrainShare?* This field is required.
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Unique ID
Should be Empty: