Six
Industry
Partner
Levels
INDUSTRY PARTNER MEMBERSHIP APPLICATION – 2017
Please complete and return to:
IIAN, 8231-B Northwoods Dr., Lincoln NE 68505 * PHONE 402-476-2951 * 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_________________________________________________________________________
STREET ADDRESS_________________________________________________________________________
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, and it is understood not to include membership in the Independent Insurance Agents and Brokers of America, and that
no logo of IIABA may be used by the named applicant without IIABA’s permission. Permission is hereby granted to IIAN 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 www.iian.org
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,
[email protected]
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: ____________________________________________