INSURANCE AGENT AFFILIATE MEMBERSHIP APP.
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