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FAIA Membership Application

Online Version (Mastercard or Visa only) - if you would like a printable version to fax or mail to FAIA, please click here.

 

Florida Association of Insurance Agents MEMBERSHIP APPLICATION
I hereby apply for the membership of my agency in the Florida Association of Insurance Agents. I certify that my agency is eligible for membership pursuant to the requirements prescribed in Section 1, Article III of the Constitution as printed on the reverse side hereof. I agree to observe the Bylaws and rules of the Association. Dues are based on the total amount of the latest calendar year's revenues from Property, Casualty, Life, Accident and Health insurance, but excluding contingency and investment income. All branch offices must become members of FAIA along with the main office. If you have any branch offices, please photocopy this form and complete one for each location. All agency locations must pay dues based on that location's individual revenues as reflected in the schedule below. Since IIABA membership dues are included with the main office payment, branch dues are discounted. This discount may vary each year.

The revenue of this location is: $.

The association’s fiscal year begins September 1 and ends August 31; dues will be prorated on a quarterly basis for new members only. 

Dues Schedule
SECTION - I Agency Information:
Application Type:
FAIA ID No.:
(if you have one)
* Principal, Owner, or Branch Manager:  
* Agency/Company Name:  
Referred By:
* Street Address  
* City:  
State:
* 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.
FAIA Dues Information:
This location is a:
P & C Revenues $:
Category Code:
L & H Revenues $:
Total Revenues $:
Category Code:
Note:  Category Code in Total Revenues is capped at one category higher than P & C Revenues.

SECTION II - Employee Count
To determine the dues that state associations pay to IIABA, FAIA must provide IIABA with a listing of each of our agencies, along with the total number of employees working in each of those agencies. 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'

My total number of "employees" as defined above is:  
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 membership.
Miscellaneous Information
Current E&O Carrier:
E&O Expiration Date:
Why your agency decided to join FAIA?
Please have someone contact me regarding: E&O Insurance:
C.E./Webinar Bundles:
Advertising:
RLI:
Technology Services:
Trusted Choice:
Young Agents Council:
Independent Market Solutions:
Florida Insurance Research Library:


SECTION III - Payment & Credit Card Information:
A percentage of the dues are non-deductible as a business expense. The estimated non-deductible portion of dues for FY 2009-2010 is 15.05%.
Total Dues $:
Suggested IMPACT dues (see chart above) $:
Suggested FAIAPAC dues (see chart above)$:
Total to be Charged on Card$:
* Credit Card:
* Credit Card No: ---  
* V-Code:  
* Expiration Date: (mm/yy)  
* Credit Card Billing Address:  
* City:  
State:
* Zip:  
* Name on Card:  
SECTION IV - Authorization
Membership cannot be accepted without an authorized name entered below and a copy of the primary agent's license.

I understand that, unless I submit a written request to the contrary, my agency name and/or contact information may be listed in general directories and appropriate FAIA documents.

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.
License No.  
Agency Owner or Principal:  
Enter First Name for Correspondence:  

3159 Shamrock South | Tallahassee, FL 32309

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