Deadline to Sign Up: August 27, 2021

Please note: Only employees of IIANC agency/branch members and IIANC PARTNER Program participants are eligible to serve on committees (membership and PARTNER Program participation must remain current throughout 2021-22 year)
  

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* 1. First Name:

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* 2. Last Name:

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* 3. Agency/Company:

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* 4. City:

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* 5. Email Address:

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* 6. Cell Phone Number:

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* 7. Date of Birth (MM/DD/YY):

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* 8. Years Experience in Insurance Industry

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* 9. What is your role in the agency/company?

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* 10. What line(s) of insurance do you work in mostly? Check all that apply.

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* 11. What is your race/ethnicity?

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* 12. What is your gender?

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* 13. Please mark the committee(s) that you would be interested in serving on September 2021 - August 2022. We will attempt to place as many first choices as possible but may be limited by space/budget constraints. If you wish to serve on more than one committee, please mark all of those as "first choice". Learn more about committee focus, meeting frequency/style, etc. at www.iianc.com/committees.

  First Choice Second Choice Third Choice
Agency Technology
Diversity
Government Affairs
iLEAD (Young Agents - age 41 & under through 8/31/22 or less than 5 years experience)
Membership Engagement
Technical

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* 14. Please share any other comments or information that should be considered when making committee appointments for 2021-22.

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