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Registration for On-Demand Webinar
You will receive the on-demand webinar link at the completion of this survey.
If you have any questions contact us at diversity@iiaba.net for further assistance.
1.
First and Last Name
2.
Email
3.
Name of Agency or Company
4.
City
5.
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia (DC)
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
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
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Other (please specify)
6.
What best describes your affiliation with Independent Insurance Agents and Brokers of America (the Big I)?
Big I Member Agency Owner
Big I Member Agent or Agency Staff
Big I Association Leader
Big I Company Partner
No Current Affiliation
Other / Unsure
7.
Can we add you to the Big I Diversity Council's monthly distribution?
Yes, please add me!
No, not at this time.
8.
Are you interested in learning more about mentorship programs for women and/or agency owners?
Yes, I am interested in receiving information on mentorship programs for women!
Yes, I am interested in receiving information on mentorship programs for agency owners!
Yes, I am interested in receiving information on both mentorship programs for women and agency owners!
No, not at this time
9.
The Big "I" has special resources for diverse agents identifying as a racial/ethnic minority, under the age of 40, woman and/or LGBTQ. Please check all that apply and note your response is OPTIONAL.
Woman
Racial or ethnic minority
Under 40 Years Old
LGBTQ
None of the Above
