Insurance Carrier Application

The INA looks to partner with Carriers, Wholesalers, and Program Administrators seeking distribution with our Networks. An application fee of $1500 will be invoiced at the time of application acceptance and renews annually. Membership dues do not include registration fees for events. Membership dues are non-refundable.

You can expect to be contacted within 2-3 business days of submitting your application.

Insurance Carrier Membership Application

Company Details

Name of Company *

Street Address *

Address 2

City/Town *

Country *

State/Province *

Zip/Postal Code *

Phone *

Website *

Current A.M. Best Rating

States Operated In

Please list Networks contracted with

Categories you underwrite

If Other, specify here

Primary Contact

Primary Contact First Name *

Primary Contact Last Name *

Primary Contact Email *

Primary Contact Phone

Please list names, telephone numbers, and emails of those company representatives most likely to participate in carrier activities

Participant 1

Participant 1 First Name

Participant 1 Last Name

Participant 1 Email

Participant 1 Phone

Participant 2

Participant 2 First Name

Participant 2 Last Name

Participant 2 Email

Participant 2 Phone

Participant 3

Participant 3 First Name

Participant 3 Last Name

Participant 3 Email

Participant 3 Phone