Please complete all entries below and submit. Payment will be made using PayPal. Membership Type*Agency (Independent Agent/Agency) $400 + $50 one-time initiation feeAssociate (Other than Agent/Agency) $500 + $100 one-time initiation feeAffiliate (Agents beyond 90 miles of closest Chapter) $95 + $50 one-time feefor office use onlyBusiness Name*Business Email* Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Business Phone*Mobile PhoneBusiness Website* Referred byHow many employees do you have in your agency?*How many years have you been in business?*What are the reasons you joined the LAAIA?* Advocacy Education Leadership Networking Branding your agency Company Appointments What areas of insurance do you focus on?* Homeowners Auto Commercial Life and Health Information about the person that handles the accounts payables in your office.NameEmail* Phone*Voluntary Donation to LAAIA PC:*$50 DonationNot at this timeFor information on the LAAIA PC click here Political Contributions are not tax deductible. Election laws require us to use our best efforts to collect and report the individual or company name, mailing address, and occupation, of those who contribute in excess of $100. Total $0.00 Automatic Renewal: For your convenience, membership will automatically renew on your anniversary date NameThis field is for validation purposes and should be left unchanged.