_agencyname = ''; _email = ''; _name0 = ''; _title0 = ''; _email0 = ''; _name1 = ''; _title1 = ''; _email1 = ''; _name2 = ''; _title2 = ''; _email2 = ''; _name3 = ''; _title3 = ''; _email3 = ''; _phone = ''; _fax = ''; _type = ''; _typeinfo = ''; _otherlocation = ''; _otherlocationinfo = ''; _businesscategory = ''; _address = ''; _city = ''; _state = ''; _zip = ''; _urlweb = ''; _independent_brokerage_percentage = ''; _ppgaproduction_percentage = ''; _inhouse_captiveagents_percentage = ''; _personalproduction_percentage = ''; _registeredproduct_percentage = ''; _AK_agents = ''; _HI_agents = ''; _MI_agents = ''; _NV_agents = ''; _UT_agents = ''; _AL_agents = ''; _IA_agents = ''; _MN_agents = ''; _NY_agents = ''; _VA_agents = ''; _AR_agents = ''; _ID_agents = ''; _MO_agents = ''; _OH_agents = ''; _VT_agents = ''; _AZ_agents = ''; _IL_agents = ''; _MS_agents = ''; _OK_agents = ''; _WA_agents = ''; _CA_agents = ''; _IN_agents = ''; _MT_agents = ''; _OR_agents = ''; _WI_agents = ''; _CO_agents = ''; _KS_agents = ''; _NC_agents = ''; _PA_agents = ''; _WV_agents = ''; _CT_agents = ''; _KY_agents = ''; _ND_agents = ''; _RI_agents = ''; _WY_agents = ''; _DC_agents = ''; _LA_agents = ''; _NE_agents = ''; _SC_agents = ''; _Other_agents = ''; _DE_agents = ''; _MA_agents = ''; _NH_agents = ''; _SD_agents = ''; _FL_agents = ''; _MD_agents = ''; _NJ_agents = ''; _TN_agents = ''; _GA_agents = ''; _ME_agents = ''; _NM_agents = ''; _TX_agents = ''; _good_business_standing = ''; __51percent_owned_by_pricipals = ''; _insurance_company_controlled = ''; _insurance_company_owned = ''; _insurance_company_owned_explination = ''; __3_or_more_companies_12_new_cases = ''; _provisional_number_of_carriers_direct_contact = ''; _carriers_which_agency_has_independent_wholesale_direct_brokerage_general_agent_contact = ''; _payment = ''; _credit_card_number = ''; _name_on_card = ''; _exp_date = ''; if (isDefined("session.agencyname")){ _agencyname = session.agencyname; StructDelete(session, "agencyname"); } if (isDefined("session.email")){ _email = session.email; StructDelete(session, "email"); } if (isDefined("session.name0")){ _name0 = session.name0; StructDelete(session, "name0"); } if (isDefined("session.title0")){ _title0 = session.title0; StructDelete(session, "title0"); } if (isDefined("session.email0")){ _email0 = session.email0; StructDelete(session, "email0"); } if (isDefined("session.name1")){ _name1 = session.name1; StructDelete(session, "name1"); } if (isDefined("session.title1")){ _title1 = session.title1; StructDelete(session, "title1"); } if (isDefined("session.email1")){ _email1 = session.email1; StructDelete(session, "email1"); } if (isDefined("session.name2")){ _name2 = session.name2; StructDelete(session, "name2"); } if (isDefined("session.title2")){ _title2 = session.title2; StructDelete(session, "title2"); } if (isDefined("session.email2")){ _email2 = session.email2; StructDelete(session, "email2"); } if (isDefined("session.name3")){ _name3 = session.name3; StructDelete(session, "name3"); } if (isDefined("session.title3")){ _title3 = session.title3; StructDelete(session, "title3"); } if (isDefined("session.email3")){ _email3 = session.email3; StructDelete(session, "email3"); } if (isDefined("session.phone")){ _phone = session.phone; StructDelete(session, "phone"); } if (isDefined("session.fax")){ _fax = session.fax; StructDelete(session, "fax"); } if (isDefined("session.type")){ _type = session.type; StructDelete(session, "type"); } if (isDefined("session.typeinfo")){ _typeinfo = session.typeinfo; StructDelete(session, "typeinfo"); } if (isDefined("session.otherlocation")){ _otherlocation = session.otherlocation; StructDelete(session, "otherlocation"); } if (isDefined("session.otherlocationinfo")){ _otherlocationinfo = session.otherlocationinfo; StructDelete(session, "otherlocationinfo"); } if (isDefined("session.businesscategory")){ _businesscategory = session.businesscategory; StructDelete(session, "businesscategory"); } if (isDefined("session.address")){ _address = session.address; StructDelete(session, "address"); } if (isDefined("session.city")){ _city = session.city; StructDelete(session, "city"); } if (isDefined("session.state")){ _state = session.state; StructDelete(session, "state"); } if (isDefined("session.zip")){ _zip = session.zip; StructDelete(session, "zip"); } if (isDefined("session.urlweb")){ _urlweb = session.urlweb; StructDelete(session, "urlweb"); } if (isDefined("session.independent_brokerage_percentage")){ _independent_brokerage_percentage = session.independent_brokerage_percentage; StructDelete(session, "independent_brokerage_percentage"); } if (isDefined("session.ppgaproduction_percentage")){ _ppgaproduction_percentage = session.ppgaproduction_percentage; StructDelete(session, "ppgaproduction_percentage"); } if (isDefined("session.inhouse_captiveagents_percentage")){ _inhouse_captiveagents_percentage = session.inhouse_captiveagents_percentage; StructDelete(session, "inhouse_captiveagents_percentage"); } if (isDefined("session.personalproduction_percentage")){ _personalproduction_percentage = session.personalproduction_percentage; StructDelete(session, "personalproduction_percentage"); } if (isDefined("session.registeredproduct_percentage")){ _registeredproduct_percentage = session.registeredproduct_percentage; StructDelete(session, "registeredproduct_percentage"); } if (isDefined("session.AK_agents")){ _AK_agents = session.AK_agents; StructDelete(session, "AK_agents"); } if (isDefined("session.HI_agents")){ _HI_agents = session.HI_agents; StructDelete(session, "HI_agents"); } if (isDefined("session.MI_agents")){ _MI_agents = session.MI_agents; StructDelete(session, "MI_agents"); } if (isDefined("session.NV_agents")){ _NV_agents = session.NV_agents; StructDelete(session, "NV_agents"); } if (isDefined("session.UT_agents")){ _UT_agents = session.UT_agents; StructDelete(session, "UT_agents"); } if (isDefined("session.AL_agents")){ _AL_agents = session.AL_agents; StructDelete(session, "AL_agents"); } if (isDefined("session.IA_agents")){ _IA_agents = session.IA_agents; StructDelete(session, "IA_agents"); } if (isDefined("session.MN_agents")){ _MN_agents = session.MN_agents; StructDelete(session, "MN_agents"); } if (isDefined("session.NY_agents")){ _NY_agents = session.NY_agents; StructDelete(session, "NY_agents"); } if (isDefined("session.VA_agents")){ _VA_agents = session.VA_agents; StructDelete(session, "VA_agents"); } if (isDefined("session.AR_agents")){ _AR_agents = session.AR_agents; StructDelete(session, "AR_agents"); } if (isDefined("session.ID_agents")){ _ID_agents = session.ID_agents; StructDelete(session, "ID_agents"); } if (isDefined("session.MO_agents")){ _MO_agents = session.MO_agents; StructDelete(session, "MO_agents"); } if (isDefined("session.OH_agents")){ _OH_agents = session.OH_agents; StructDelete(session, "OH_agents"); } if (isDefined("session.VT_agents")){ _VT_agents = session.VT_agents; StructDelete(session, "VT_agents"); } if (isDefined("session.AZ_agents")){ _AZ_agents = session.AZ_agents; StructDelete(session, "AZ_agents"); } if (isDefined("session.IL_agents")){ _IL_agents = session.IL_agents; StructDelete(session, "IL_agents"); } if (isDefined("session.MS_agents")){ _MS_agents = session.MS_agents; StructDelete(session, "MS_agents"); } if (isDefined("session.OK_agents")){ _OK_agents = session.OK_agents; StructDelete(session, "OK_agents"); } if (isDefined("session.WA_agents")){ _WA_agents = session.WA_agents; StructDelete(session, "WA_agents"); } if (isDefined("session.CA_agents")){ _CA_agents = session.CA_agents; StructDelete(session, "CA_agents"); } if (isDefined("session.IN_agents")){ _IN_agents = session.IN_agents; StructDelete(session, "IN_agents"); } if (isDefined("session.MT_agents")){ _MT_agents = session.MT_agents; StructDelete(session, "MT_agents"); } if (isDefined("session.OR_agents")){ _OR_agents = session.OR_agents; StructDelete(session, "OR_agents"); } if (isDefined("session.WI_agents")){ _WI_agents = session.WI_agents; StructDelete(session, "WI_agents"); } if (isDefined("session.CO_agents")){ _CO_agents = session.CO_agents; StructDelete(session, "CO_agents"); } if (isDefined("session.KS_agents")){ _KS_agents = session.KS_agents; StructDelete(session, "KS_agents"); } if (isDefined("session.NC_agents")){ _NC_agents = session.NC_agents; StructDelete(session, "NC_agents"); } if (isDefined("session.PA_agents")){ _PA_agents = session.PA_agents; StructDelete(session, "PA_agents"); } if (isDefined("session.WV_agents")){ _WV_agents = session.WV_agents; StructDelete(session, "WV_agents"); } if (isDefined("session.CT_agents")){ _CT_agents = session.CT_agents; StructDelete(session, "CT_agents"); } if (isDefined("session.KY_agents")){ _KY_agents = session.KY_agents; StructDelete(session, "KY_agents"); } if (isDefined("session.ND_agents")){ _ND_agents = session.ND_agents; StructDelete(session, "ND_agents"); } if (isDefined("session.RI_agents")){ _RI_agents = session.RI_agents; StructDelete(session, "RI_agents"); } if (isDefined("session.WY_agents")){ _WY_agents = session.WY_agents; StructDelete(session, "WY_agents"); } if (isDefined("session.DC_agents")){ _DC_agents = session.DC_agents; StructDelete(session, "DC_agents"); } if (isDefined("session.LA_agents")){ _LA_agents = session.LA_agents; StructDelete(session, "LA_agents"); } if (isDefined("session.NE_agents")){ _NE_agents = session.NE_agents; StructDelete(session, "NE_agents"); } if (isDefined("session.SC_agents")){ _SC_agents = session.SC_agents; StructDelete(session, "SC_agents"); } if (isDefined("session.Other_agents")){ _Other_agents = session.Other_agents; StructDelete(session, "Other_agents"); } if (isDefined("session.DE_agents")){ _DE_agents = session.DE_agents; StructDelete(session, "DE_agents"); } if (isDefined("session.MA_agents")){ _MA_agents = session.MA_agents; StructDelete(session, "MA_agents"); } if (isDefined("session.NH_agents")){ _NH_agents = session.NH_agents; StructDelete(session, "NH_agents"); } if (isDefined("session.SD_agents")){ _SD_agents = session.SD_agents; StructDelete(session, "SD_agents"); } if (isDefined("session.FL_agents")){ _FL_agents = session.FL_agents; StructDelete(session, "FL_agents"); } if (isDefined("session.MD_agents")){ _MD_agents = session.MD_agents; StructDelete(session, "MD_agents"); } if (isDefined("session.NJ_agents")){ _NJ_agents = session.NJ_agents; StructDelete(session, "NJ_agents"); } if (isDefined("session.TN_agents")){ _TN_agents = session.TN_agents; StructDelete(session, "TN_agents"); } if (isDefined("session.GA_agents")){ _GA_agents = session.GA_agents; StructDelete(session, "GA_agents"); } if (isDefined("session.ME_agents")){ _ME_agents = session.ME_agents; StructDelete(session, "ME_agents"); } if (isDefined("session.NM_agents")){ _NM_agents = session.NM_agents; StructDelete(session, "NM_agents"); } if (isDefined("session.TX_agents")){ _TX_agents = session.TX_agents; StructDelete(session, "TX_agents"); } if (isDefined("session.good_business_standing")){ _good_business_standing = session.good_business_standing; StructDelete(session, "good_business_standing"); } if (isDefined("session._51percent_owned_by_pricipals")){ __51percent_owned_by_pricipals = session._51percent_owned_by_pricipals; StructDelete(session, "_51percent_owned_by_pricipals"); } if (isDefined("session.insurance_company_controlled")){ _insurance_company_controlled = session.insurance_company_controlled; StructDelete(session, "insurance_company_controlled"); } if (isDefined("session.insurance_company_owned")){ _insurance_company_owned = session.insurance_company_owned; StructDelete(session, "insurance_company_owned"); } if (isDefined("session.insurance_company_owned_explination")){ _insurance_company_owned_explination = session.insurance_company_owned_explination; StructDelete(session, "insurance_company_owned_explination"); } if (isDefined("session._3_or_more_companies_12_new_cases")){ __3_or_more_companies_12_new_cases = session._3_or_more_companies_12_new_cases; StructDelete(session, "_3_or_more_companies_12_new_cases"); } if (isDefined("session.provisional_number_of_carriers_direct_contact")){ _provisional_number_of_carriers_direct_contact = session.provisional_number_of_carriers_direct_contact; StructDelete(session, "provisional_number_of_carriers_direct_contact"); } if (isDefined("session.carriers_which_agency_has_independent_wholesale_direct_brokerage_general_agent_contact")){ _carriers_which_agency_has_independent_wholesale_direct_brokerage_general_agent_contact = session.carriers_which_agency_has_independent_wholesale_direct_brokerage_general_agent_contact; StructDelete(session, "carriers_which_agency_has_independent_wholesale_direct_brokerage_general_agent_contact"); } if (isDefined("session.payment")){ _payment = session.payment; StructDelete(session, "payment"); } if (isDefined("session.credit_card_number")){ _credit_card_number = session.credit_card_number; StructDelete(session, "credit_card_number"); } if (isDefined("session.name_on_card")){ _name_on_card = session.name_on_card; StructDelete(session, "name_on_card"); } if (isDefined("session.exp_date")){ _exp_date = session.exp_date; StructDelete(session, "exp_date"); }

Online Application

#session.errmsg#

#url.errmsg#

* AGENCY NAME:

STREET ADDRESS:

CITY:

STATE:

ZIP:

WEB SITE:

* E-MAIL:

* PHONE:

FAX:

CHECK ONE:

checked /> Corporation Partnership
checked /> Sole Proprietor
checked /> Other (please specify)

DOES YOUR AGENCY HAVE MORE THAN ONE LOCATION? :

checked /> No
checked /> Yes (Please list)

PRINCIPAL DESIGNATED AS PRIMARY CONTACT AND EMPOWERED TO VOTE FOR THE AGENCY:
Principal Name

Principal Title

Principal Email

AGENCY OFFICERS:

Name: Title: Email

PLEASE CHECK EVERY CATEGORY IN WHICH YOU CONDUCT BUSINESS:
Life
Impaired Risk
Annuities
Disability
Employee Benefit Plans
Health
Broker/Dealer

Indicate the percentage of your agency production in each of the following categories:
Independent Brokerage (%):
PPGA Production(%):
In-house/Captive Agents (%) :
Personal Production(%) :
Registered Product(%) :

Indicate all the states in which the agency does business by adding the number of agents to each state:

AK:	HI:	MI:	NV:	UT:
AL:	IA:	MN:	NY:	VA:
AR:	ID:	MO:	OH:	VT:
AZ:	IL:	MS::	OK:	WA:
CA:	IN:	MT:	OR:	WI:
CO:	KS:	NC:	PA:	WV:
CT:	KY:	ND:	RI:	WY:
DC:	LA:	NE:	SC:	Other:
DE:	MA:	NH:	SD:
FL:	MD:	NJ:	TN:
GA:	ME:	NM:	TX:

Are the agency, and all principals and officers, in good standing in all of the states and with all companies with which it does business?
checked value="no" /> No
checked value="yes" /> Yes

Is 51% or more of your agency owned by principals active in this business?
checked /> No
checked /> Yes

Is the agency controlled by any insurance company or an insurance company subsidary?
checked /> No
checked /> Yes

Does any insurance company or its subsidary have any ownership interest in the agency?
checked /> No
checked /> Yes (please provide any pertinent details)

Do you do business with three (3) or more life and/or health insurance companies and place at least 12 new cases per year with each?
checked /> No
checked /> Yes

If you are applying for membership in the Provisional category please make note here of the number of carriers with which you have direct reporting contact:

List all carriers with which the agency has an independent wholesale direct brokerage general agent contact and has placed no less than twelve months new in-force cases during the past twelve months. Note that provisional membership allows for less than three (3) direct reporting contracts.

Payment Information

checked /> Mastercard
checked /> Visa
checked /> AmEx
checked /> Check
Amt Due: $1,195.00

Card Number:

Name on Card:

Exp Date:

Note: In addition to this form, send an application letter from at least three of the companies listed above, stating that your agency has a direct reporting independent wholesale brokerage general agent contract and places at least 12 new cases with that company per calendar year. NAILBA suggests also including with your application, a letter of support or recommendation from a current NAILBA member agency letterhead. Please also include a copy or your agency's current brochure or most recent promotional material.

Note: If you are applying for Provisional Membership, please provide letters from the carriers with which you have a direct reporting contract and list the number of cases you place annually.

Please forward application, payment, and all requested documents to:

NAILBA
12150 Monument Drive
Suite 125
Fairfax, VA 22033

Phone: (703) 383-3081
Fax: (703) 383-6942

Membership Dues may be deductible under Section 162 of the IRS Code as "ordinary and necessary business expenses." However, contributions or gifts to NAILBA are not deductible as charitable contribution for Federal Income tax purposes with the exception of 10% of the annual dues which may be used for lobbying activities.

Applications will not be processed until all requested documentation and payment has been recieved.