Print this application and complete it to join the Cincinnati Insurance Board.

Agency Name:  ______________________________________________________________________

Street Address: ______________________________________________________________________

P.O. Box:: __________________________________________________________________________

City and State: __________________________________________________  Zipcode_____________

Phone: _________________________  Fax: ________________________

Internet Address:___________________________ E-Mail Address:______________________________

Branch Office(s)________________________________________________________________________

Licensed Employees;include principals, producers & other Licensed Personnel: (Use separate list if necessary)

1___________________________________________  11______________________________________

2___________________________________________  12______________________________________

3___________________________________________  13______________________________________

4___________________________________________  14______________________________________

5___________________________________________  15______________________________________

6___________________________________________  16______________________________________

7___________________________________________  17______________________________________

8___________________________________________  18______________________________________

9___________________________________________  19______________________________________

10__________________________________________  20______________________________________

Other Association Membership                                       Total Licensed Employees: ______________

IIAO ______ PIA ______                                                                                                  X $125.00

                                                                                    Total Membership Dues:   $______________

Send this application along with your check to: The Greater Cincinnati Insurance Board
                                                                     5535 Fair Lane, Suite A
                                                                     Cincinnati, Ohio 45227