Membership Application - Associate

Thank you for your interest in becoming an IIAV Associate Member. We greatly appreciate your interest and look forward to working with you!

This application is for an Associate. Once the form is completed, you will receive an email with more details regarding payment. Please feel free to contact us with any questions or concerns.

Insurance Company Fee: $1,000

Non-Insurance Vendor Fee: $500

Stevenson Cocke | Director of Membership

scocke@iiav.com

(804) 747-9300

Fields marked with an * are required.

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Contact Info

Type of Business *

Type of Business Other

Agency Name *

Main Contact *

First and Last Name

Street Address *

City *

State *

Zip Code *

Phone *

Toll Free

Fax

Email Address *

Web Address *

Mailing Address

Is the Mailing Address different from Street Address

Mailing Address

If different from Street Address

Mailing City

Mailing State

Mailing Zip Code

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Other Details

How did you hear about us?

Other Important Information

Are there any other details you would like IIAV to know?

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