INDUSTRY PARTNER MEMBERSHIP APPLICATION – 2017
Please complete and returnto:
IIAN, 8231-B Northwoods Dr., Lincoln NE 68505*PHONE402-476-2951 * FAX 402-476-1586
______Diamond Level ($8,500.00)______Silver Level ($2,500.00)
______Platinum Level ($5,500.00)______Bronze Level ($1,000.00)
______Gold Level ($3,500.00)______Copper Level ($500.00)
COMPANY NAME______
STREETADDRESS______
CITY______STATE______ZIP ______
MAILING ADDRESS (IF DIFFERENT FROM STREET ADDRESS):______
CITY ______STATE ______ZIP ______
PHONE NUMBER ______FAX NUMBER______
PRIMARY CO. REP.______E-MAIL:______
WEB ADDRESS: ______
TERRITORY/STATES OF BUSINESS: ____ Nebraska Only _____ Other States: ______
______
MARKETING REP:______E-MAIL: ______
MAILING ADDRESS (if different from above):______
______MKT REP PREFERRED PHONE: ______
MARKETING REP: ______E-MAIL: ______
MAILING ADDRESS (if different from above):______
______MKT REP PREFERRED PHONE: ______
This application is hereby tendered for IIAN Partner Program/associate membership in the Independent Insurance Agents of Nebraska, andit is understood not to include membership in the Independent Insurance Agents and Brokers of America, and that nologo of IIABA may be used by the named applicant without IIABA’s permission. Permission is hereby granted toIIAN to include information on this application on IIAN’s website and promotional materials.
Name:______Title:______
Signature:______Date:______
COMPLETE OTHER SIDE TO UPDATE WEB SITE DIRECTORY & JOIN MARKET SEARCH!!
Independent Insurance Agents of Nebraska
For our Online Partner Directory
Information will be included on
Besides the company contact information, we will include the following information on our directory:
Major Products/Services/Lines: ______
______
______
Agri-Business, Farm Products/Lines (if any):______
______
______
Company Description (in 25 words or less) your company,which will be included on our website:
______
______
______
______
OPTIONAL:
Market Search Service: We have a market search service, where our members will be able to request more information about a particular market they need. (Home/Auto/WC/Vacant Building/Umbrella etc.) That email request will then be forwarded along to ALL our Industry Partners, regardless of the type of risk. If you can be of service to our members, you will have the necessary information to contact them. This will provide a snapshot of the markets that our members are looking for.
We will be happy to work with the representative that you want to receive these emails, as well as ensure that we have your available markets listed in our request form.
Email Service Contact Name: ______
Email Service Contact Phone: ______
Email to send Market Requests to: ______
Call or e-mail the IIAN office if you have any questions — (402) 476-2951 in Lincoln,
Are you interested in becoming involved within IIAN on a Task Force or Committee? If so, please let us know your contact info:
Name: ______Email: ______