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