2003/2004 Membership Application

Remit Payment to:         

Independent Insurance Agents of Greater Tampa
PO Box 271081, Tampa, FL 33688
This is an online application form. Since we are not currently accepting credit cards, you can either:

  1. Fill in the form below and then mail your check to above address. 

  2. Fax in the printable form and mail your check to above address.

  3. Print the form and mail it in with your check to above address. 

Click here for a printer friendly version of the IIAGT Membership Application (requires Acrobat Reader - see below).

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This is a free download. Click on the Icon below to get your free copy.
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Regular  Associate
Date: 
(I / We) hereby request membership with the Independent Insurance Agents Association of Greater Tampa. 
(I / We) have engaged in the local agency business in Hillsborough County since 

Insurance is is not our principal business.

Other business(es) in which we are engaged include:

Dues for membership renewal are $300.00 annually for regular and associate members if paid on or before September 1, 2003. Dues paid after September 1st are $325.00. Regular member applicants, please add $35.00 for each additional agent in excess of one acting in a producer capacity. Dues include luncheon cost at general membership meetings for one representative from each agency/company. Make checks payable to IIAGT.

The fully licensed agent who will vote on behalf of our agency is:

(Only Regular Members will have voting privileges.)

(I / We) agree to abide by all rules and regulations as set forth in the By-laws of the Association.
Person Responsible for Membership:
Title:
Agency/Company Name:
Contact Person:
Street Address:
City:
State:
Zip
Mailing Address, If Different
Phone: Fax
E-mail
Names of Licensed Agents in Above Agency (if applicable); Include E-Mail Address (REQUIRED):
List Any Other Locations Maintained by the (if applicable):
 
 

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