Professional Association of Nebraska and Iowa

Membership in PIA is an invaluable tool to help you succeed in the insurance industry. To join online with a credit card or check, simply fill out the form below. If you would prefer to join via mail, please use the printable form.

Name of Agency:

Mailing Address:

PO Box:

City:

State:

Zip Code:

Country:

Phone Number:

Fax Number:

Email Address:

Website Address:

Name and Designations:

Date of Birth (i.e. 05/05/1965):

Gender:

Employment Status:

Part-Time:

Agency Information

Agency type:

Associations affiliated with:

Top 3 P&C Companies (list in order):

1:

2:

3:

Which Agency Management System are you using?:

E&O Carrier:

Expiration Date (i.e. 05/05/2005):

Annual P&C Premium Volume:

Payment Information (Part-time employees count as one-half. If count ends in half, drop half.):

Total Agency Size:

First Name as it appears on card:

Last Name as it appears on card.:

Credit Card Number:

Card Expiration Month:

Card Expiration Year:

To pay by check, please print form and mail to:

PIA Association for Nebraska & Iowa
920 South 107th Ave, Ste 305
Omaha, NE 68114

Forms can also be faxed to 402-392-2228.

Checks for dues should be made payable to:
PIA of Nebraska

Return with check payable to:
PIA of Nebraska, 920 S 107 Ave, Suite 305, Omaha, NE 68114

PIAPAC contributions are not deductible as charitable contributions
but may be allowable as a business expense. Consult your tax advisor on this.

Yes, I would like to support (PIAPAC) Nebraska Insurance
Political Action Committee and have enclosed
my personal check for $____________

Name: __________________________________________
Agency: _________________________________________
Address: _____________________________ City/State/Zip: _______________
Phone:_______________________________Fax:________________________

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