Please complete the following questions for membership in the Greater Cincinnati Insurance Board.
 

Agent's Name: _________________________________________________________________________

Agency Name: _________________________________________________________________________

Street Address:  ________________________________________________________________________

P. O. Box:  ____________________________________________________________________________

City: ____________________________________   State: ________  Zipcode: _____________________

Phone: __________________________________ FAX: _____________________________

If you would like other licensed employees in your agency to receive the benefits of membership in the CIB, list them below.

Licensed employees

1 _______________________________________   4 _________________________________________

2 _______________________________________   5 _________________________________________

3 _______________________________________   6 _________________________________________
 

Affiliate Dues  (includes two licensed employees)                                                              $250.00

Additional Licensed employees                                                       _____    X  $125.00 = _______

                                                                                                        Total                      _______

 Make your check payable to the Cincinnati Insurance Board.

Print this application and send it to:  The Greater Cincinnati Insurance Board
                                                      5535 Fair Lane, Suite A
                                                      Cincinnati, Ohio 45227