Joliet-Will County
Independent Insurance Agents' Association

Application for Membership
Agency Name:  _______________________________________________ Date: ____/____/______
Address:  _______________________________________________ Il License # __________
   _______________________________________________ County __________
   _______________________   _______   _______ - _____    

 

Telephone #s Office : (_____) ______ - ___________ eMail : ___________@____________________
       
Fax : (_____) ______ - ___________ Web Site: http://www.__________________________

 

Companies Represented by the Agency:

  
   
   
   
   
   

 

Agency is:

B Individual

  B Partnership

 B Corporation

 

Employees working 20 hours or more each week on Property/Casualty business {licensed or not}.

    
Name Hours / week Position
________________________________   __________   ___________________
________________________________   __________   ___________________
________________________________   __________   ___________________
________________________________   __________   ___________________
________________________________   __________   ___________________
________________________________   __________   ___________________

 

About your Agency

    
Are you a licensed life and/or Health Insurance Agency? B Yes B No  
Is your full time occupation General Insurance?  B Yes B No  
Is your agency automated?  B Yes B No  
Multi User?  B Yes B No  
Agency Manager:   B No B Yes   ____________________________
Automated Rating:   B No B Yes   ____________________________

 

_________________________________ _________________________________
Print Owner's Names Owner's Signatures

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