*Required Information
+Qualification Information - will not be published in directory.

*Agency Name
*Principal #1 Last Name
First Name
Principal #2 Last Name
First Name
Principal #3 Last Name
First Name
Principal #4 Last Name
First Name
*Address
*City
*State *ZIP
*Phone FAX
*Email
Website
*Other Agency Locations? Yes  No
If yes, please be sure to include your website address
to assist readers in locating your branch office.
 
   Insurance Industry Marketing / Study Group Memberships
American Brokerage Centers, LLC Argyle Group
Brokerage Resources of America Brokers Health Insurance Network, Inc.
Capitas Financial, LLC Consolidated Marketing Group
CPS Insurance Services Diversified Marketing Group
iGroup Insurance Designers
LIFE, Inc. LifeMark Partners
National Association of Insurance Marketers National Brokerage Agency
National Brokerage Consortium National Insurance Producers
National LTC Network Plus Group
Risk Appraisal Forum SUB Centers
The Marketing Alliance 

Other Insurance Industry Organization Memberships  (enter one per line)
 
  *Check All States In Which Agency Does Business
Alabama Alaska Arizona
Arkansas California Colorado
Connecticut Delaware District of Columbia
Florida Georgia Hawaii
Idaho Illinois Indiana
International Iowa Kansas
Kentucky Louisiana Maine
Maryland Massachusetts Michigan
Minnesota Mississippi Missouri
Montana Nebraska Nevada
New Hampshire New Jersey New Mexico
New York North Carolina North Dakota
Ohio Oklahoma Oregon
Pennsylvania Puerto Rico Rhode Island
South Carolina South Dakota Tennessee
Texas Utah Vermont
Virginia Washington West Virginia
Wisconsin Wyoming 
 
Years in Business Agency    Principal
 
  *Products Sold
Ancillary Products
Benefit Discount Card Dental Insurance
Legal Plan Prescription Drug
Stand Alone Drug Card Vision Insurance

Annuities
403(b) Annuities Bonus Annuities
Deferred Annuities Equity Indexed Annuities
Fixed Annuities Gift Annuities
Immediate Annuities Indexed Annuities
Medicaid Annuities Single Premium Deferred Annuities
Single Premium Immediate Annuities Variable Annuities

Disability
Accident Only Blue Collar
Business Overhead Expense Buy / Sell
Impaired Risk Key Person
Long Term Payroll Deduction
Short Term 

Employee Benefits
401(k) 403(b)
Cafeteria Plan / Section 125 Non-Qualified Pension Plans
Pension Plans Qualified Pension Plans
Simplified Employee Pension (SEP) Voluntary Benefits

Financial Planning
Affluent Market Estate Planning
Mortgage Acceleration Retirement Planning
Trusts 

Group Insurance
Accident AD&D
Association Benefit Discount Card
Cafeteria Plans Cancer
Critical Illness Dental
Disability HMO
Large Group (100-499) Large Group (500+)
Legal Plan Life
Long Term Care Medical
Medium Group (11-99) METs
MSAs PPO
Prescription Drugs Retiree Medical
Self Insured Small Group (1-10)
Special Risk Term
TPA Universal Life
Vision 

Health
Accidental Death Cafeteria Plan / Section 125
Cancer Plan College Student Health Plan
Critical Illness Dread Disease
Flexible Spending Accounts Group
Guarantee Issue / Simplified Issue Health Purchasing
HMO Individual
International Long Term Care
Major Medical Medical Savings Accounts (MSAs)
Medicare Supplement PPO Network
Qualified Plans Self Funded
Short Term Medical Supplemental Health

International Coverage
Foreign National Health Foreign National Life
International Health International Life
International Major Medical Travel Accident

Life
Accelerated Benefits Annual Renewable Term
COLI Credit Insurance
Decreasing Term Deposit Term
Final Expense First To Die
General Life Group
Guarantee Issue / Simplified Issue Guaranteed Renewable Term
High Issue Age HIV
Impaired Risk Indexed Life
Interest Sensitive Life Interest Sensitive Whole Life
International Joint Life
Juvenile Key Person
Level Term Mortgage Insurance
Renewable Term Second To Die
Single Premium Life Single Premium Universal Life
Single Premium Whole Life Survivorship Life
Term Life Universal Life
Variable Life Variable Universal Life
Voluntary Whole Life

Life Settlements / Viatical Settlements
Living Benefits 

Other Investments
CDs IRAs
Mutual Funds Securities

Other Services
Incentives Leads
Online Services Seminar Training

Senior Market
Disability Income Long Term Care
Medicare Supplement Retiree Health Care
Retiree Medical Senior Annuities
Senior Health Senior Life

Worksite
Payroll Deduction Payroll Life
Voluntary Benefits 
+*Is Agency NAILBA Member?
  Yes  No
 
+*List at least 3 companies with which you currently have a BGA or Wholesaler contract: (enter one per line)
 
+*Do you wish to have these carriers listed on your information page in the following manner: "Representing fine carriers such as:"
  Yes  No
 
+*Have you placed 12 or more new cases per year with at least 3 brokerage carriers?
  Yes  No
 
+*Production Percentage
% Brokerage % PPGA
% Personal % Other
 
+*Number of Agents With Whom You Do Business  
 
  Number of Employees  
 
I am interested in enhancing my listing with a hyperlink to my website, my logo, a banner and/or banner ad.
 
*Required Information
+Qualification Information - will not be published in directory.

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