Thank you for your interest in IA&B's Member Agent Panels.

Please complete the information and click "submit."

First Name

Last Name

Agency Name

Agency Address

City

State

Zip Code

Telephone (XXX-XXX-XXXX)

Fax Number (XXX-XXX-XXXX)

E-mail Address

What is your position in the agency

Number of employees in agency (including yourself):

1-5 employees 6-10 employees 11-15 employees 16-20 employees 21+ employees

How many years have you been in the insurance industry?

I want to be on a Member Agent Panel to:

Have voice heard

Network with other members

Be more involved in the organization

Become a future leader of IA&B

Other

Which location would you prefer (please select a location in your home state):

Pledge of Commitment. If appointed, I commit to attend 2, 3-hour meetings per year for 2 years. I will actively participate and offer opinions and expertise to ensure that the issues, concerns and ideas of members are being voiced to improve IA&B and the insurance industry.

I Agree