New Member Agreement–Confidential

Thank you for your interest in the Florida Association of Insurance Agents. Dues are based on an agency’s total revenue from Property, Casualty, Life, Accident and Health insurance (excluding contingency and investment income) for the latest calendar year. The total includes revenue from all additional locations, if applicable. Membership in IIABA and Trusted Choice are included in your dues.

STEP 1. Determine your agency's total revenues:
*P&C revenues: $  
*LA&H revenues: $  
*Total Revenues: $   DO NOT EDIT

Click here to view the dues schedule

STEP 2. Determine your total dues payment:
*Agency/main office total dues:
(based on category in dues schedule) 		$  DO NOT EDIT
*Additional Location Total Dues:
(based on category in dues schedule) 		No. of Additional Locations x $ = $0  
*Total Annual Dues: $   DO NOT EDIT
STEP 3. Main office information:
* Principal, Owner, or Branch Manager:  
*License Number:  
* Agency/Company Name:  
* Street Address  
* City:  
State:
* Zip:  
* County:  
Mailing Address:
Mailing City:
Mailing State:
Mailing Zip:
* Phone:  
* Fax:  
* Principal Email:  
Agency Website
Trusted Choice® License Agreement
 
STEP 4. Determine your employee count:
To determine the dues that state associations pay to IIABA, FAIA must provide the total number of employees, including employees at satellite locations, working in each agency. This information is held in strict confidence and will be used only by FAIA to compile the total number of individual insurance personnel employed by our members. Please use the following definition of "employees."
"Employees include all officers, owners, partners, producers, and other licensed or unlicensed employees and independent contractors who further the work of the agency or brokerage firm, wherever located in this state, whether involved with insurance, employee benefits, other financial services, or the administrative functions of the agency. Those who work 30+ hours per week should be counted as "1." Those who work under 30 hours should be counted as "1/2."
The total number of employees at my agency, as defined above is:
STEP 5. Credit Card Information
The association’s fiscal year begins Sept. 1 and ends Aug. 31. A percentage of the dues are non-deductible as a business expense. The estimated non-deductible portion of dues for FY 2012-2013 is 44.87%.
*Credit Card:
*Credit Card Number:               
*CVV Code:  
*Expiration Date (mm/yy):  
*Billing Address:  
*Billing City:  
*Billing State:
*Billing Zip:  
*Name On Card:  
STEP 6. Authorization:
By providing the fax number and e-mail above, I consent to the receipt of e-mail, faxes, and all other correspondence sent to this office or additional locations from FAIA, FAIA Member Services, and IIABA and its subsidiaries. My signature verifies that I have the authority to provide such consent.

I certify that my agency is eligible for membership pursuant to the requirements prescribed in Section 1, Article III of the Constitution of the Florida Association of Insurance Agents. I attest that the information included in this application is correct and that I will adhere to the association’s Constitution and Bylaws.

Electronically Signed by
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