Apply to Join

Step 1 of 3

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*
Address*
Address Line 1 Address Line 2 City State ZIP Code
Mailing Address (if different)
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Website*
Main Contact Name
First Last
Direct Phone or Extension*
Email*
Billing Contact Name*
First Last
Direct Phone or Extension*
Email*
Please describe your organization. What do you do in relation to wholesale insurance?*

Choose Your Member Type*
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Wholesaler fields
Taxpayer ID #*
CA License #*
What percentage of your business is received from wholesalers?*
What percentage of your business is received from retailers?*
What percentage of your business is conducted directly with the customer or applicant?*
What percentage of your business is written in non-admitted insurers?*
What percentage of your business is received from affiliated organizations?*
Please list your primary markets.*
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.*
List owners and percentage of ownership.*
Name Title Percentage
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Associate fields
Compliance Dept Contact Name*
First Last
Direct Phone or Extension*
Email*
Classification of your organization (e.g., Company, Reinsurer, Lloyd's Broker, etc.).*
Please list agents or brokers you do business with or who represent you in California.*
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)
Hidden
Supporting fields
List owners and percentage of ownership.*
Name Title Percentage
Please list products or services that you provide to wholesalers and to the insurance industry.*

Name	Title	Percentage

Name	Title	Percentage

Step 1 of 3

Wholesaler fields

Associate fields

Optional: Additional office contact(s)

Supporting fields