Associate Membership Application

SECTION - I Agency Information:
(if you have one)
* Principal, Owner, or Branch Manager:  
Referred By:
* Company Name:  
* Street Address  
* City:  
* Zip:  
* County:  
Mailing Address:
Mailing City:
Mailing State:
Mailing Zip:
* Phone:  
* Fax:  
* Principal Email:  
Web Address
Please check if you do not want your fax and e-mail to be published in the FAIA Membership Directory or on the FAIA Website.
Type of business:
If Other:
Describe your Business:
(250 character limit)

Associate Member Category Descriptions:

Life Health and Benefits($750.00)— Florida independent agencies or companies that do no P&C business who would like to affiliate with those who do.

Insurance Company ($2000.00)— Any P&C insurance company or similar risk-bearing entity seeking affiliation with independent agents.

Other Insurance Industry Affiliate ($750.00) — Entities having affinity relationships with the insurance industry or with insurance agents—i.e., premium finance
companies, automation vendors, adjusting firms, law firms, industry consultants, publishers and third party administrators.

Insurance Wholesaler ($750.00) — Entities who derive a majority of their revenues from non-retail insurance sales and none from Florida retail
insurance sales (if so this entity should join as a regular member). Examples are E&S agencies, Managing General Agents, Reinsurance
Intermediaries, and the like.

Insurance Agency In-Eligible for Regular Membership ($750.00) — Insurance agencies not eligible for membership under Article III of the FAIA Constitution other than exclusive
direct writing agencies.

Entities not falling into one of the above categories are either not eligible to join FAIA, or must join as full, voting members under Article
III, Section I of the FAIA Constitution as follows:

…firms or corporations: which are actively, though not exclusively, engaged in the business of property and casualty insurance;
which have within their organization one or more agents, in possession of a valid license; who represent a duly licensed property
and casualty company or companies that recognize a member’s ownership of expirations; who are independent agents who
operate as independent contractors of property and casualty insurance companies; who are of good business reputation and
who have had experience and training, or are otherwise qualified

SECTION II - Payment & Credit Card Information:
Amount to be Charged on Credit Card:
* Credit Card:
* Credit Card No: ---  
* V-Code:  
* Expiration Date: (mm/yy)  
* Credit Card Billing Address:  
* City:  
* Zip:  
* Name on Card:  

SECTION III - Authorization
Membership cannot be accepted without an authorized name entered below and a copy of the primary agent's license.

Agreement Statement

I do hereby attest that the information above is correct and that I will adhere to the Constitution and Bylaws of the Florida Association of Insurance Agents.
Agency Owner or Principal:  
Enter First Name for Correspondence: