The Agents Association represents over 1,000 members across a twelve-state region.
Based on your state a dues schedule will be assigned and you will either be billed directly or your dues will be commission deducted.
By sending this form, I am authorizing The Agents Association to commission deduct my regional and state dues for the current year and every subsequent year I am a member. I understand that by providing the email address, phone and fax numbers listed on this page, on behalf of the company or organization specified above, I am authorized to and hereby provide consent for the company/organization to receive emails, phone calls and faxes sent by or on behalf of The Agents Association. Information provided on this form will be used for Association purposes only.
Long Term Disability Wavier: If you do not wish to participate and decline all LTD Coverage, you must email email@example.com or firstname.lastname@example.org. I understand this is my one-time opportunity to enroll without having to go through underwriting and in the future if I elect this coverage it will be subject to evidence insurability at my expense.