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All CIWA memberships must be approved before members can be added. For all applicants seeking Wholesaler, Associate, or Supporting membership, please fill out the form below. Partners and Media should please contact us via our main contact form.

Company Name(Required)

Address(Required)

Address Line 1 Address Line 2 City State ZIP Code

Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Fax

Website(Required)

Main Contact Name

First Last

Direct Phone or Extension(Required)

Email(Required)

Billing Contact Name(Required)

First Last

Direct Phone or Extension(Required)

Email(Required)

Please describe your organization. What do you do in relation to wholesale insurance?(Required)

Choose Your Member Type(Required)

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Wholesaler fields

Taxpayer ID #(Required)

CA License #(Required)

What percentage of your business is received from wholesalers?(Required)

What percentage of your business is received from retailers?(Required)

What percentage of your business is conducted directly with the customer or applicant?(Required)

What percentage of your business is written in non-admitted insurers?(Required)

What percentage of your business is received from affiliated organizations?(Required)

Please list your primary markets.(Required)

Has any member of your firm or a related firm been subjected to any disciplinary action by any State Insurance Department or other regulators? Please explain or enter N/A.(Required)

List owners and percentage of ownership.(Required)

Name

Title

Percentage

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Associate fields

Compliance Dept Contact Name(Required)

First Last

Direct Phone or Extension(Required)

Email(Required)

Classification of your organization (e.g., Company, Reinsurer, Lloyd's Broker, etc.).(Required)

Please list agents or brokers you do business with or who represent you in California.(Required)

Optional: Additional office contact(s)

Name

First Last

Email

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

First Last

Email

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

First Last

Email

Phone

Address

Street Address Address Line 2 City State ZIP Code

If more than three additional office contacts, please upload list here.

Accepted file types: pdf, docx, doc, xls, xlsx, Max. file size: 256 MB.

File types accepted: PDF, Word (doc, docx), Excel (xls, xlsx)

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Supporting fields

List owners and percentage of ownership.(Required)

Name

Title

Percentage

Please list products or services that you provide to wholesalers and to the insurance industry.(Required)

Number of Employees(Required)

Are you a member of:

WSIA

Other

List other organizations

During the past two (2) years, has your firm acquired or merged with another firm, or changed its name? Please explain or enter N/A.(Required)

Is your firm engaged in, owned by, associated with, or controlled by another company? Please explain or enter N/A.(Required)

Are you engaged in any other business? Please explain or enter N/A.(Required)

How did you hear about CIWA?(Required)

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Wholesaler fields

Associate fields

Optional: Additional office contact(s)

Supporting fields

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