Network App

Network Membership Application

Name of Network *

Street Address *

Address 2

City/Town *

Country *

State/Province *

Zip/Postal Code *

Email *

Phone *

Please describe your Network’s management structure, goals and the type of agencies you best serve

Year network established (Enter 4-digit year)

How many agency members does the Network have?

How much premium is controlled by the Network?

What services & resources does the Network provide (beside market access)?

Top commercial lines carriers

Top personal lines carriers

List any special programs and/or coverages the network has

List agency qualifications to join your network:

Minimum Premium/Revenue

Employee Count

Other Criteria

Describe your ideal agency candidate

What is your product mix by %?

Product mix (%): Property & Casualty

Life

Annuity/Investments

Health

Other

Membership Coordinator (for INA Networks Directory use)

Name

Title

Phone

Primary Contact First Name *

Primary Contact Last Name *

Primary Contact Email *

Primary Contact Phone

How did you hear about the INA?