Membership Application - Agency - Independent Insurance Agents of Virginia

Membership Application - Agency

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

This application is for an Agency Membership. Once completed, you will receive an email with more details regarding payment and individual employee sign-ups. Please feel free to contact us with any questions or concerns.

Stevenson Cocke | Director of Membership

scocke@iiav.com

(804) 747-9300

Fields marked with an * are required.

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Contact Info

Product Lines *

Please select all that apply

Property & Causality

Life & Health

Workers Comp

Personal

Commercial

Employee Benefits

Other

Product Lines Other

Agency Name *

Main Contact *

First and Last Name

Street Address *

City *

State *

Zip Code *

Phone *

Toll Free

Fax

Email Address *

Number of Licensed Employees *

Membership pricing is based on the number of Licensed Employees who will have access to IIAV Membership Benefits.

Number of Employees	Yearly Dues Amount
1	$525.00
2	$630.00
3	$1,000.00
4	$1,350.00
5	$1,575.00
6	$1850.00
7 - 10	$2,100.00
11 - 15	$2,370.00
16 - 20	$2,625.00
21 - 25	$2,900.00
26 - 30	$3,255.00
31 - 39	$3,700.00
40 - 49	$4,300.00
50 - 99	$8,950.00
100+	$9,200.00

Dues can be paid monthly.

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

E&O Carrier

E&O Exp. Date

100 words max

How did you hear about us?

Other Important Information

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

Please verify that you have checked the “I'm not a robot” checkbox.

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