2021 PIMA Summer Insights Conference Registration Form

Registrant Information

Please complete one registration form for each registrant. Once your online registration is completed you will receive an email confirmation with conference and housing link.

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* Registrant Contact Information

Name:

(Name for Badge)

Title

Company Name

City

State

Phone

Email Address:

Question Title

* Please select your membership type:

Distributor - any entity, including any licensed agency or TPA, that generates revenue by taking a portion (percentage or fixed fee) of the value of each sales transaction.

Product Provider - any entity, including licensed insurance company, that generates their revenue by manufacturing products/services to meet the needs of a market segment.

Business Partner - any entity that generates their revenue by supplying resources/goods/services to Distributors and Product Providers.

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* Please select your current membership status: (**If not an employee of a PIMA Member Company, you are considered a "Prospective.") If you are unsure, please send an email to conference@pimainsights.org for confirmation.

Member

Prospective**

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* Special Accessibility /Dietary Restrictions

Please indicate any special accessibility requirements

Please indicate any dietary restrictions