Step 1 of 333%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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxWebsite* 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*SelectWholesalerAssociateSupportingHiddenWholesaler fieldsTaxpayer 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.*NameTitlePercentage HiddenAssociate fieldsCompliance 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 PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name First Last Email PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name First Last Email PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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)HiddenSupporting fieldsList owners and percentage of ownership.*NameTitlePercentage Please list products or services that you provide to wholesalers and to the insurance industry.*Number of Employees*Are you a member of: WSIA OtherList other organizationsDuring the past two (2) years, has your firm acquired or merged with another firm, or changed its name? Please explain or enter N/A.*Is your firm engaged in, owned by, associated with, or controlled by another company? Please explain or enter N/A.*Are you engaged in any other business? Please explain or enter N/A.*How did you hear about CIWA?*Referred by current CIWA memberReferred by CIWA Board MemberReferred by management company (Direct Connection)WebsiteMarketingEventI agree* By clicking Submit, I agree to the privacy policy and membership policy as presented on this website.I authorize CIWA to use my information to contact me in the future to conduct further business.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.