Big I Diversity Council Mentorship Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Agency/Company Name* This field is required.
3
Job Title* This field is required.
4
State * This field is required.
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
Washington D.C.
West Virginia
Wisconsin
Wyoming
5
Email* This field is required.
example@example.com
6
Phone* This field is required.
7
Preferred method of communication.* This field is required.
Email
Phone
8
Are you interested in being a mentor or mentee?
Mentor
Mentee
9
Preferred mentorship duration.
One-time
1 month
3 months
6 months
Other
10
What do you need help with?Select all that apply.
Carrier relationships
Commercial Lines
Growth & scaling
Hiring & Training
Operations
Personal Lines
Personal Development
Sales/production
Starting an agency
Technology
Other
11
Are there any specific questions or challenges you'd like to discuss with your mentor?
Huge
Large
Normal
Small
Ok
Ok
12
Please select your level of experience.
1-5 years
5-10 years
10+ years
13
Areas of ExpertiseSelect all that apply.
Carrier relationships
Commercial Lines
Growth & scaling
Hiring & Training
Operations
Personal Lines
Starting an agency
Sales/production
Technology
Other
14
How much time are you willing to commit per month?
1-2 hours
2-4 hours
4+ hours
15
Why are you interested in being a mentor?
Huge
Large
Normal
Small
Ok
Ok
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